Provider Demographics
NPI:1477800514
Name:KENNEDY, MELISSA GRAY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:GRAY
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:ANNE
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2515 E NC HIGHWAY 54
Mailing Address - Street 2:BLDG 2200
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-5263
Mailing Address - Country:US
Mailing Address - Phone:919-493-0959
Mailing Address - Fax:919-493-0970
Practice Address - Street 1:2515 E NC HIGHWAY 54
Practice Address - Street 2:BULIDING 2200
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-5263
Practice Address - Country:US
Practice Address - Phone:919-493-0959
Practice Address - Fax:919-493-0970
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-08
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0094821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical