Provider Demographics
NPI:1225576051
Name:KENNEDY, BETH (BCBA)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 CHURCH ST
Mailing Address - Street 2:19TH FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-2100
Mailing Address - Country:US
Mailing Address - Phone:888-261-1110
Mailing Address - Fax:866-696-7991
Practice Address - Street 1:157 CHURCH ST
Practice Address - Street 2:19TH FLOOR
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-2100
Practice Address - Country:US
Practice Address - Phone:888-261-1110
Practice Address - Fax:866-696-7991
Is Sole Proprietor?:No
Enumeration Date:2017-01-31
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1-16-23983103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst