Provider Demographics
NPI:1265664403
Name:KENNEDY, MAXWELL B (MFT)
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:B
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 373
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-0373
Mailing Address - Country:US
Mailing Address - Phone:912-682-2709
Mailing Address - Fax:912-764-5661
Practice Address - Street 1:106 OAK ST STE A
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0988
Practice Address - Country:US
Practice Address - Phone:912-682-2709
Practice Address - Fax:912-764-5661
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-21
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT000585106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist