Provider Demographics
NPI:1437206653
Name:KENNEDY, WILLIAM DOUGLAS (PSYD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:DOUGLAS
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 944
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-0944
Mailing Address - Country:US
Mailing Address - Phone:937-383-3565
Mailing Address - Fax:937-383-0156
Practice Address - Street 1:1550 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-1031
Practice Address - Country:US
Practice Address - Phone:937-902-8857
Practice Address - Fax:937-383-0156
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5171103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2005341Medicaid
OH261453Medicare UPIN
OH000000211115Medicare UPIN
OH7787050Medicare UPIN
OH2005341Medicaid