Provider Demographics
NPI:1275294613
Name:KENNEDY, SHEILA LAURREN
Entity Type:Individual
Prefix:MRS
First Name:SHEILA
Middle Name:LAURREN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11215 JOHN GALT BLVD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-2319
Mailing Address - Country:US
Mailing Address - Phone:402-592-5900
Mailing Address - Fax:402-592-5901
Practice Address - Street 1:11215 JOHN GALT BLVD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-2319
Practice Address - Country:US
Practice Address - Phone:402-592-5900
Practice Address - Fax:402-592-5901
Is Sole Proprietor?:No
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1185101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1073874731Medicaid