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NPI Code Detail

MEDICARE: KENNEDY RUSSELL

MEDICARE: KENNEDY RUSSELL
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106S00000XBehavior TechnicianBACB1539733MD

General Provider Information

NPI Number : 1073469490
Entity Type Code : Individual
Provider Name (Legal Business Name) : KENNEDY RUSSELL
Provider Business Mailing Address
First Line : 9701 APOLLO DR STE 100
Second Line :
City : UPPER MARLBORO
State : MD
Zip : 20774-4785
Country : US
Telephone Number : 301-456-4787
Fax Number :
Provider Business Practice Location Address
First Line : 9701 APOLLO DR STE 100
Second Line :
City : UPPER MARLBORO
State : MD
Zip : 20774-4785
Country : US
Telephone Number : 301-456-4787
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/09/2026
Last Update Date : 03/09/2026

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Directions to “ KENNEDY RUSSELL ” Practice Location

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