Provider Demographics
NPI:1265501670
Name:KENNEDY, SUSAN D (MS, NCC, LPC)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:D
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MS, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3422 VINTAGE WOODS DRIVE
Mailing Address - Street 2:
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026
Mailing Address - Country:US
Mailing Address - Phone:614-445-8131
Mailing Address - Fax:
Practice Address - Street 1:1160 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43222-1352
Practice Address - Country:US
Practice Address - Phone:614-274-1455
Practice Address - Fax:614-274-1433
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.110216-SUPV101YM0800X
MO2001031746101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0235855Medicaid