Provider Demographics
NPI:1043334618
Name:KENNEDY, KIMBERLY AYLENE (M A)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:AYLENE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:M A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1886
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28026-6007
Mailing Address - Country:US
Mailing Address - Phone:704-436-6762
Mailing Address - Fax:
Practice Address - Street 1:1065 VINEHAVEN DR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2439
Practice Address - Country:US
Practice Address - Phone:704-286-9181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1829103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical