Provider Demographics
NPI:1043432461
Name:KENNEDY, EMILY MARY (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:MARY
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-2200
Mailing Address - Country:US
Mailing Address - Phone:508-363-4544
Mailing Address - Fax:508-753-5100
Practice Address - Street 1:198 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-2200
Practice Address - Country:US
Practice Address - Phone:508-363-4544
Practice Address - Fax:508-753-5100
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10305131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP20970Medicare ID - Type Unspecified