1083762108 NPI number — MELISSA FOURNIER KENNEDY PT, OCS

Table of content: MELISSA FOURNIER KENNEDY PT, OCS (NPI 1083762108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083762108 NPI number — MELISSA FOURNIER KENNEDY PT, OCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENNEDY
Provider First Name:
MELISSA
Provider Middle Name:
FOURNIER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, OCS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FOURNIER
Provider Other First Name:
MELISSA
Provider Other Middle Name:
FOURNIER
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, DPT, OCS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1083762108
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
143 LONGWATER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORWELL
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02061-1683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-878-5200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
143 LONGWATER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORWELL
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02061-1683
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-878-5200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/08/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  18230 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: 007666 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)