Provider Demographics
NPI:1477079077
Name:KENNEDY, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 COACHLIGHT SQ
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:NY
Mailing Address - Zip Code:10548-1252
Mailing Address - Country:US
Mailing Address - Phone:914-261-0254
Mailing Address - Fax:
Practice Address - Street 1:30 BUXTON FARM RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-1224
Practice Address - Country:US
Practice Address - Phone:203-674-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-17-26472103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst