=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790830610
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY ALAN KENNEDY PH.D., L.I.S.W.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6827 N HIGH ST 121
-----------------------------------------------------
City | WORTHINGTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43085-2517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-436-5070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9468 CHESHIRE RD
-----------------------------------------------------
City | SUNBURY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43074-9543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-965-2145
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I-492
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------