Provider Demographics
NPI:1033839337
Name:COLLINS, KENNEDY J
Entity Type:Individual
Prefix:
First Name:KENNEDY
Middle Name:J
Last Name:COLLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2965 PHARR COURT SOUTH NW APT 516
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-2139
Mailing Address - Country:US
Mailing Address - Phone:626-616-9079
Mailing Address - Fax:
Practice Address - Street 1:5163 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30342-2206
Practice Address - Country:US
Practice Address - Phone:877-288-4760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty