Provider Demographics
NPI:1386656205
Name:KENNEDY, BROOKE ALLISON (PT, DPT)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ALLISON
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5629
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47716-5629
Mailing Address - Country:US
Mailing Address - Phone:812-476-0409
Mailing Address - Fax:812-476-1016
Practice Address - Street 1:5625 PEARL DR
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47712-8106
Practice Address - Country:US
Practice Address - Phone:812-759-7493
Practice Address - Fax:812-401-2346
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009061A225100000X
KY005611225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000485787OtherBLUE CROSS BLUE SHIELD
KY000000674191OtherANTHEM BCBS
KYKY005611OtherKY PT LICENSE
IN200829320Medicaid
IN000000485787OtherBLUE CROSS BLUE SHIELD
INP00375475Medicare UPIN