Healthcare Provider Details

I. General information

NPI: 1487465183
Provider Name (Legal Business Name): KENNEDY MOORE BCABA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2025
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 W GLEN PARK AVE
GRIFFITH IN
46319-2028
US

IV. Provider business mailing address

905 W GLEN PARK AVE
GRIFFITH IN
46319-2028
US

V. Phone/Fax

Practice location:
  • Phone: 219-501-1729
  • Fax:
Mailing address:
  • Phone: 219-501-1729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: