Healthcare Provider Details

I. General information

NPI: 1417936527
Provider Name (Legal Business Name): NICOLE CRISTTIN KENNEDY LCSW C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 02/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 FALLSWAY HEALTH CARE FOR THE HOMELESS
BALTIMORE MD
21202-4800
US

IV. Provider business mailing address

421 FALLSWAY HEALTH CARE FOR THE HOMELESS
BALTIMORE MD
21202-4800
US

V. Phone/Fax

Practice location:
  • Phone: 410-837-5533
  • Fax: 410-837-8020
Mailing address:
  • Phone: 410-837-5533
  • Fax: 410-837-8020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11939
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: