Provider Demographics
NPI:1538446844
Name:KENNUTH, ROBERT MARTIN
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:MARTIN
Last Name:KENNUTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4805 TRANSIT RD APT 2903
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-4911
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:329 PORTER AVE
Practice Address - Street 2:D'YOUVILLE COLLEGE
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14201
Practice Address - Country:US
Practice Address - Phone:716-829-8309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001014-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer