=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629482518
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE MARIE KENNEY PSYCHOLOGY, B.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2014
-----------------------------------------------------
Last Update Date | 07/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 447 W 47TH ST SUITE 1
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10036-2453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-829-1837
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 61 CLIVE ST
-----------------------------------------------------
City | METUCHEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08840-1039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-829-1837
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------