Provider Demographics
NPI:1225302029
Name:KENNEDY, SALLY ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:ANN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 S MILLEDGE AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30605-1350
Mailing Address - Country:US
Mailing Address - Phone:706-296-1202
Mailing Address - Fax:
Practice Address - Street 1:1160 S MILLEDGE AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30605-1350
Practice Address - Country:US
Practice Address - Phone:706-296-1202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2915103T00000X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist