Healthcare Provider Details

I. General information

NPI: 1275959421
Provider Name (Legal Business Name): WILLIAM KENNEDY LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2014
Last Update Date: 12/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3633 WHEELER RD SUITE 365
AUGUSTA GA
30909-6549
US

IV. Provider business mailing address

3633 WHEELER RD SUITE 365
AUGUSTA GA
30909-6549
US

V. Phone/Fax

Practice location:
  • Phone: 706-825-9300
  • Fax: 706-432-8775
Mailing address:
  • Phone: 706-825-9300
  • Fax: 706-432-8775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAADC
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC007699
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: