Provider Demographics
NPI:1992415970
Name:EDDY, KENDELYN JADE (PTA)
Entity type:Individual
Prefix:
First Name:KENDELYN
Middle Name:JADE
Last Name:EDDY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 ROUSCH DR
Mailing Address - Street 2:
Mailing Address - City:WESTOVER
Mailing Address - State:WV
Mailing Address - Zip Code:26501-3872
Mailing Address - Country:US
Mailing Address - Phone:304-598-6099
Mailing Address - Fax:
Practice Address - Street 1:12 ROUSCH DR
Practice Address - Street 2:
Practice Address - City:WESTOVER
Practice Address - State:WV
Practice Address - Zip Code:26501-3872
Practice Address - Country:US
Practice Address - Phone:304-598-6099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-30
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002002225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant