Healthcare Provider Details

I. General information

NPI: 1306116066
Provider Name (Legal Business Name): MICHAEL SHAWN KENNEDY SCHOOL PSYCHOLOGIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2012
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 HAWK DR
DULCE NM
87528
US

IV. Provider business mailing address

113 HAWKS DR
DULCE NM
87528
US

V. Phone/Fax

Practice location:
  • Phone: 575-759-3225
  • Fax: 575-759-3533
Mailing address:
  • Phone: 575-759-3225
  • Fax: 575-759-3533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number344005
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: