Provider Demographics
NPI:1346511250
Name:KENNEDY, EMMA
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:
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 1:15 CONNECTICUT AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145-2110
Mailing Address - Country:US
Mailing Address - Phone:734-657-4118
Mailing Address - Fax:
Practice Address - Street 1:380 PLEASANT ST STE 12
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-8127
Practice Address - Country:US
Practice Address - Phone:781-396-6530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-24
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA1198681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program