Healthcare Provider Details

I. General information

NPI: 1053009464
Provider Name (Legal Business Name): KENNEDY HAVERLAND LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2023
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 GENERAL CHENNAULT ST NE
ALBUQUERQUE NM
87123-2515
US

IV. Provider business mailing address

126 GENERAL CHENNAULT ST NE
ALBUQUERQUE NM
87123-2515
US

V. Phone/Fax

Practice location:
  • Phone: 505-900-3833
  • Fax: 505-212-6422
Mailing address:
  • Phone: 505-900-3833
  • Fax: 505-212-6422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2025-0878
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSWB-2023-0169
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: