Provider Demographics
NPI:1376078568
Name:KENNEDY, CAITLIN BREE (DAC, LAC)
Entity Type:Individual
Prefix:MRS
First Name:CAITLIN
Middle Name:BREE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DAC, LAC
Other - Prefix:MS
Other - First Name:CAITLIN
Other - Middle Name:BREE
Other - Last Name:NESPOLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:133 ROOSEVELT AVENUE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762
Mailing Address - Country:US
Mailing Address - Phone:516-884-5215
Mailing Address - Fax:
Practice Address - Street 1:507 HICKSVILLE ROAD
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758
Practice Address - Country:US
Practice Address - Phone:516-884-5215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-25
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005786171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist