Provider Demographics
NPI:1528459690
Name:KENNELLY, THERESA CATHERINE
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:CATHERINE
Last Name:KENNELLY
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 1:12100 W CENTER RD STE 518
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-3960
Mailing Address - Country:US
Mailing Address - Phone:402-933-2882
Mailing Address - Fax:
Practice Address - Street 1:12100 W CENTER RD STE 518
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-3960
Practice Address - Country:US
Practice Address - Phone:402-933-2882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-11
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2472225X00000X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other