MEDICARE: MYKAEL KENNEDY

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

General Provider Information

NPI Number	:	1639046923
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MYKAEL KENNEDY

Provider Business Mailing Address
First Line	:	945 N CENTRAL AVE
Second Line	:
City	:	WOODMERE
State	:	NY
Zip	:	11598-1604
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7903 PROVIDENCE RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-9720
Country	:	US
Telephone Number	:	704-440-3580
Fax Number	:

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

Provider Enumeration Date	:	10/21/2025
Last Update Date	:	02/16/2026

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Directions to “ MYKAEL KENNEDY ” Practice Location

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