Provider Demographics
NPI:1073097721
Name:KENNEDY, ELIZABETH DUCK (MA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:DUCK
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 PALISADE ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-4527
Mailing Address - Country:US
Mailing Address - Phone:901-359-3997
Mailing Address - Fax:
Practice Address - Street 1:6363 POPLAR AVE STE 404
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4831
Practice Address - Country:US
Practice Address - Phone:901-302-9588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3310101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health