Healthcare Provider Details

I. General information

NPI: 1972307478
Provider Name (Legal Business Name): BRIAN J KENNEDY CAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2025
Last Update Date: 12/06/2025
Certification Date: 12/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

352 STATE ST
NORTH HAVEN CT
06473-3108
US

IV. Provider business mailing address

204 WINSLOW DR
WEST HAVEN CT
06516-6917
US

V. Phone/Fax

Practice location:
  • Phone: 203-781-4600
  • Fax:
Mailing address:
  • Phone: 203-435-0242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1617
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number11232
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: