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General NPI Number Information
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NPI Number | 1265664403
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Entity Type | Individual
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Provider Name | MAXWELL B KENNEDY MFT
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Gender | Male
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Dates
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Enumeration Date | 08/21/2009
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Last Update Date | 08/21/2009
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Provider Practice Location Address
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Address Line | 106 OAK ST STE A
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City | STATESBORO
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State | GA
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Zip | 30458-0988
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Country | US
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Telephone | 912-682-2709
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Fax | 912-764-5661
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Provider Business Mailing Address
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Address Line | PO BOX 373
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City | STATESBORO
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State | GA
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Zip | 30459-0373
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Country | US
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Telephone | 912-682-2709
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Fax | 912-764-5661
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MFT000585
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License Number State | GA
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