Healthcare Provider Details

I. General information

NPI: 1033438643
Provider Name (Legal Business Name): KENNEDY HEALTH SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2010
Last Update Date: 05/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

454 HURFFVILLE CROSSKEYS RD
SEWELL NJ
08080-2339
US

IV. Provider business mailing address

2201 CHAPEL AVE W
CHERRY HILL NJ
08002-2048
US

V. Phone/Fax

Practice location:
  • Phone: 856-582-1419
  • Fax: 856-582-7661
Mailing address:
  • Phone: 856-488-6500
  • Fax: 856-488-6415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. RUSS MICOLI
Title or Position: CORP. DIRECTOR, BEHAVIORAL HEALTH
Credential: MA, MHA
Phone: 856-488-6701