Provider Demographics
NPI:1376999409
Name:KENNEDY, MARCIA (LCP, LSCSW)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LCP, LSCSW
Other - Prefix:
Other - First Name:MARCIA
Other - Middle Name:
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCP, LSCSW
Mailing Address - Street 1:1113 N VALLEYVIEW ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-4367
Mailing Address - Country:US
Mailing Address - Phone:316-371-7226
Mailing Address - Fax:888-527-4437
Practice Address - Street 1:654 N WOODCHUCK ST STE F
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-3571
Practice Address - Country:US
Practice Address - Phone:316-371-7226
Practice Address - Fax:888-527-4437
Is Sole Proprietor?:No
Enumeration Date:2016-05-07
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS46951041C0700X
KS1498103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS81-2454443Medicaid