Provider Demographics
NPI:1366866048
Name:KENNEDY, MARTRICE (LSW)
Entity Type:Individual
Prefix:
First Name:MARTRICE
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:MARTRICE
Other - Middle Name:
Other - Last Name:GASKINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1401 S 31ST STREET
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146
Mailing Address - Country:US
Mailing Address - Phone:215-925-2400
Mailing Address - Fax:215-925-9162
Practice Address - Street 1:4510 FRANKFORD AVE FL 2
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-3602
Practice Address - Country:US
Practice Address - Phone:215-831-9882
Practice Address - Fax:215-831-9887
Is Sole Proprietor?:No
Enumeration Date:2014-02-14
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health