Provider Demographics
NPI:1386774206
Name:KENNEDY, ELIZABETH (PTA)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:ELIZABETH
Other - Middle Name:K
Other - Last Name:RAYMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3860 AMBER RD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13215-8679
Mailing Address - Country:US
Mailing Address - Phone:315-469-1207
Mailing Address - Fax:
Practice Address - Street 1:800 S WILBUR AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204-2732
Practice Address - Country:US
Practice Address - Phone:315-473-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002595-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant