Provider Demographics
NPI:1245398262
Name:KENNEDY, RANDALL WORLEY (LPC)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:WORLEY
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:PAMPA
Mailing Address - State:TX
Mailing Address - Zip Code:79065-4302
Mailing Address - Country:US
Mailing Address - Phone:806-688-0096
Mailing Address - Fax:806-688-0096
Practice Address - Street 1:1224 N HOBART ST
Practice Address - Street 2:SUITE 1
Practice Address - City:PAMPA
Practice Address - State:TX
Practice Address - Zip Code:79065-4606
Practice Address - Country:US
Practice Address - Phone:806-688-0096
Practice Address - Fax:806-688-0096
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17266101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX392019OtherVALUEOPTIONS
TX7224LCOtherBLUECROSS BLUE SHIELD