MEDICARE: KENNEDY'S CIRCLE OF WELLNESS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1942856091
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENNEDY'S CIRCLE OF WELLNESS LLC

Provider Business Mailing Address
First Line	:	3614 W NORTH AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53208-1416
Country	:	US
Telephone Number	:	414-346-0276
Fax Number	:	414-600-1452

Provider Business Practice Location Address
First Line	:	3614 W NORTH AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53208-1416
Country	:	US
Telephone Number	:	414-399-8736
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	SHAJUAN KENNEDY
Credential	:
Telephone Number	:	414-399-8736

Provider Enumeration Date	:	08/14/2019
Last Update Date	:	07/16/2020

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