Provider Demographics
NPI:1871958033
Name:KENNEDY, CHARLINE M (LMT)
Entity type:Individual
Prefix:
First Name:CHARLINE
Middle Name:M
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:CHARLINE
Other - Middle Name:M
Other - Last Name:HODGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:9802 QUARRY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH AMHERST
Mailing Address - State:OH
Mailing Address - Zip Code:44001-2940
Mailing Address - Country:US
Mailing Address - Phone:440-339-7933
Mailing Address - Fax:
Practice Address - Street 1:903 MAIN ST
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:OH
Practice Address - Zip Code:44044-1433
Practice Address - Country:US
Practice Address - Phone:440-926-2326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-15
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.020834225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist