Provider Demographics
NPI:1053455568
Name:KENNEDY, MARY KATHLEEN (EDDSPED,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATHLEEN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:EDDSPED,CCC-SLP
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:WOOD
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1613 GINGER DR
Mailing Address - Street 2:
Mailing Address - City:HIDEAWAY
Mailing Address - State:TX
Mailing Address - Zip Code:75771-5311
Mailing Address - Country:US
Mailing Address - Phone:903-530-8169
Mailing Address - Fax:
Practice Address - Street 1:1613 GINGER DR
Practice Address - Street 2:
Practice Address - City:HIDEAWAY
Practice Address - State:TX
Practice Address - Zip Code:75771-5311
Practice Address - Country:US
Practice Address - Phone:903-530-8169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11254235Z00000X
FLSA8471235Z00000X
MA6816235Z00000X
NM3892235Z00000X
MESP1522235Z00000X
CASP15930235Z00000X
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist