MEDICARE: KENNEDY GRACE BROGAN I

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
1	106S00000X	Behavior Technician	BACB1153990	VA

General Provider Information

NPI Number	:	1295689073
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNEDY GRACE BROGAN I

Provider Business Mailing Address
First Line	:	9395 LONDON TOWER CT UNIT 603
Second Line	:
City	:	GLEN ALLEN
State	:	VA
Zip	:	23060-3718
Country	:	US
Telephone Number	:	804-338-9396
Fax Number	:

Provider Business Practice Location Address
First Line	:	9395 LONDON TOWER CT UNIT 603
Second Line	:
City	:	GLEN ALLEN
State	:	VA
Zip	:	23060-3718
Country	:	US
Telephone Number	:	804-338-9396
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/26/2026
Last Update Date	:	02/26/2026

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