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General NPI Number Information
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NPI Number | 1891500526
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Entity Type | Individual
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Provider Name | KENNEDY SHORES
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Gender | Female
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Dates
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Enumeration Date | 02/10/2025
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Last Update Date | 04/11/2025
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Provider Practice Location Address
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Address Line | 333 W NORFOLK AVE STE 201
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City | NORFOLK
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State | NE
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Zip | 68701-5221
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Country | US
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Telephone | 402-379-2030
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Fax |
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Provider Business Mailing Address
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Address Line | 333 W NORFOLK AVE STE 201
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City | NORFOLK
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State | NE
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Zip | 68701-5221
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Country | US
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Telephone | 402-379-2030
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Fax |
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | P-2247
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License Number State | NE
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Taxonomy #2
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number | 399
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License Number State | NE
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