Provider Demographics
NPI:1205361755
Name:KENNEDY, MELANIE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 RANCHETTES RD
Mailing Address - Street 2:
Mailing Address - City:BAILEY
Mailing Address - State:CO
Mailing Address - Zip Code:80421-2051
Mailing Address - Country:US
Mailing Address - Phone:303-875-3238
Mailing Address - Fax:
Practice Address - Street 1:93 RANCHETTES RD
Practice Address - Street 2:
Practice Address - City:BAILEY
Practice Address - State:CO
Practice Address - Zip Code:80421-2051
Practice Address - Country:US
Practice Address - Phone:303-875-3238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-21
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO251C00000X, 320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO84700238Medicaid