Provider Demographics
NPI:1679596704
Name:KENNARD, MELISSA ANN (PT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:KENNARD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11201 SHAKER BLVD
Mailing Address - Street 2:SUITE 322
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44104-3869
Mailing Address - Country:US
Mailing Address - Phone:216-721-9010
Mailing Address - Fax:216-721-9188
Practice Address - Street 1:11201 SHAKER BLVD
Practice Address - Street 2:SUITE 322
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104-3869
Practice Address - Country:US
Practice Address - Phone:216-721-9010
Practice Address - Fax:216-721-9188
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT 009575225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2721030Medicaid
OH000000276538OtherANTHEM BC/BS