Healthcare Provider Details

I. General information

NPI: 1144090036
Provider Name (Legal Business Name): KENNEDY POWELL M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10074 TEN POINT RD
CANYON TX
79015-4449
US

IV. Provider business mailing address

3401 E 30TH ST
FARMINGTON NM
87402-8805
US

V. Phone/Fax

Practice location:
  • Phone: 806-690-4494
  • Fax:
Mailing address:
  • Phone: 505-599-8617
  • Fax: 855-290-2205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number115850
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSAH-2023-0236
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: