Provider Demographics
NPI:1316548704
Name:KENNEDY, DEREK MICHAEL (BA)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:MICHAEL
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 20TH AVE N
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-2503
Mailing Address - Country:US
Mailing Address - Phone:563-243-2124
Mailing Address - Fax:
Practice Address - Street 1:250 20TH AVE N
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-2503
Practice Address - Country:US
Practice Address - Phone:563-243-2124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)