MEDICARE: SUSAN EMILY 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	103K00000X	Behavior Analyst	RBT-16-16370	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659858686
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN EMILY KENNEDY

Provider Business Mailing Address
First Line	:	304 E PINE ST # 19
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33801-4969
Country	:	US
Telephone Number	:	863-614-0048
Fax Number	:	863-279-1204

Provider Business Practice Location Address
First Line	:	304 E PINE ST # 19
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33801-4969
Country	:	US
Telephone Number	:	863-614-0048
Fax Number	:	863-279-1204

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

Provider Enumeration Date	:	07/23/2018
Last Update Date	:	07/23/2018

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