Provider Demographics
NPI:1497223531
Name:KENNEDY, BRADLEY H (MRC, CRC)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:H
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MRC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 ELDER HILL RD
Mailing Address - Street 2:
Mailing Address - City:DRIFTWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:78619-2102
Mailing Address - Country:US
Mailing Address - Phone:281-202-8672
Mailing Address - Fax:
Practice Address - Street 1:1905 ELDER HILL RD
Practice Address - Street 2:
Practice Address - City:DRIFTWOOD
Practice Address - State:TX
Practice Address - Zip Code:78619-2102
Practice Address - Country:US
Practice Address - Phone:281-202-8672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111999101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)