Provider Demographics
NPI:1083872683
Name:KENNEDY, BRETTA (LCSW)
Entity Type:Individual
Prefix:
First Name:BRETTA
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:BRETTA
Other - Middle Name:
Other - Last Name:SELBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:4201 W STAN SCHLUETER LOOP
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-4782
Mailing Address - Country:US
Mailing Address - Phone:254-290-6198
Mailing Address - Fax:
Practice Address - Street 1:4201 W STAN SCHLUETER LOOP
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4782
Practice Address - Country:US
Practice Address - Phone:254-290-6198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3071041C0700X
TX575371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical