Healthcare Provider Details

I. General information

NPI: 1972563757
Provider Name (Legal Business Name): MARY M KENNEDY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS MARY S MILES

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 05/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 W PROFESSIONAL PARK CT SUITE 1
BOWLING GREEN KY
42104-3250
US

IV. Provider business mailing address

PO BOX 51322
BOWLING GREEN KY
42102-5622
US

V. Phone/Fax

Practice location:
  • Phone: 270-843-5300
  • Fax: 270-843-5383
Mailing address:
  • Phone: 270-843-5300
  • Fax: 270-843-5383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1328
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: