Provider Demographics
NPI:1356628630
Name:KENNEDY, BRAD LEE (LMP)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:LEE
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13502 SE HAROLD ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-4149
Mailing Address - Country:US
Mailing Address - Phone:503-933-8717
Mailing Address - Fax:
Practice Address - Street 1:2402 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3229
Practice Address - Country:US
Practice Address - Phone:360-241-6630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60188011171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor