Provider Demographics
NPI:1326506072
Name:THE KENNEDY COLLECTIVE, INC.
Entity Type:Organization
Organization Name:THE KENNEDY COLLECTIVE, INC.
Other - Org Name:BEHAVIORAL SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SEBASTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-365-8522
Mailing Address - Street 1:2440 RESERVOIR AVE
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-4757
Mailing Address - Country:US
Mailing Address - Phone:203-365-8522
Mailing Address - Fax:
Practice Address - Street 1:2440 RESERVOIR AVE
Practice Address - Street 2:
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-4757
Practice Address - Country:US
Practice Address - Phone:203-365-8522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE KENNEDY COLLECTIVE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-12
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004186054Medicaid