Provider Demographics
NPI:1437446119
Name:KENNEDY, SHELLY L (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:L
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:SHELLY
Other - Middle Name:L
Other - Last Name:POLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 623
Mailing Address - Street 2:
Mailing Address - City:HARWICH PORT
Mailing Address - State:MA
Mailing Address - Zip Code:02646-0623
Mailing Address - Country:US
Mailing Address - Phone:860-300-6700
Mailing Address - Fax:
Practice Address - Street 1:9 AUSTIN DR STE 201
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:CT
Practice Address - Zip Code:06447-1375
Practice Address - Country:US
Practice Address - Phone:860-300-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0073811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1437446119Medicaid
CT1437446119Medicaid