Provider Demographics
NPI:1285893974
Name:KENNEDY, SUSANNE
Entity type:Individual
Prefix:
First Name:SUSANNE
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 DURHAM RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-2676
Mailing Address - Country:US
Mailing Address - Phone:203-245-0001
Mailing Address - Fax:
Practice Address - Street 1:141 DURHAM RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-2676
Practice Address - Country:US
Practice Address - Phone:203-245-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002645225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist