Provider Demographics
NPI:1407449028
Name:KENNEDY, DEARLO (CLINICAL DIRECTOR)
Entity Type:Individual
Prefix:
First Name:DEARLO
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:CLINICAL DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S BROAD ST STE 2230
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19110-1021
Mailing Address - Country:US
Mailing Address - Phone:267-704-9669
Mailing Address - Fax:
Practice Address - Street 1:100 S BROAD ST STE 2230
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19110-1021
Practice Address - Country:US
Practice Address - Phone:267-704-9669
Practice Address - Fax:267-541-2658
Is Sole Proprietor?:No
Enumeration Date:2021-02-15
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)