Healthcare Provider Details

I. General information

NPI: 1295383883
Provider Name (Legal Business Name): KRISTEN ROSE KENNEDY M.S. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 S ROMAN DR
DIETERICH IL
62424-1162
US

IV. Provider business mailing address

205 S ROMAN DR
DIETERICH IL
62424-1162
US

V. Phone/Fax

Practice location:
  • Phone: 618-554-8874
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2020001372
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146.010301
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: