Provider Demographics
NPI:1396958450
Name:KENNEDY, FREDERICA (OTR/L, OTD)
Entity type:Individual
Prefix:
First Name:FREDERICA
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:OTR/L, OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2791 SUMMIT VALLEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019
Mailing Address - Country:US
Mailing Address - Phone:708-612-2881
Mailing Address - Fax:708-283-8685
Practice Address - Street 1:2095 HIGHWAY 211 NW STE D
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-3402
Practice Address - Country:US
Practice Address - Phone:770-207-6390
Practice Address - Fax:678-374-4855
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
IL056.006013225X00000X
GAOT006737225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003200220BMedicaid
GA003200220AMedicaid