Healthcare Provider Details

I. General information

NPI: 1215976980
Provider Name (Legal Business Name): KEVIN D. KENNEDY LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 04/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 HANCOCK ST
QUINCY MA
02169-4339
US

IV. Provider business mailing address

147 MILK ST PROVIDER ENROLLMENT 9TH FLOOR
BOSTON MA
02109-4806
US

V. Phone/Fax

Practice location:
  • Phone: 617-774-0920
  • Fax:
Mailing address:
  • Phone: 617-559-8051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103502
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: