Provider Demographics
NPI:1003582990
Name:KENNEDY, TYLER JULES (MA, LAC)
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:JULES
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 PLOCH RD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-1471
Mailing Address - Country:US
Mailing Address - Phone:973-865-5468
Mailing Address - Fax:
Practice Address - Street 1:32 MIDWOOD DR
Practice Address - Street 2:
Practice Address - City:FLORHAM PARK
Practice Address - State:NJ
Practice Address - Zip Code:07932-1811
Practice Address - Country:US
Practice Address - Phone:973-865-5468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health