Provider Demographics
NPI:1518095660
Name:KENNEDY, MARY S (MSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:S
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 FAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-1112
Mailing Address - Country:US
Mailing Address - Phone:617-497-9506
Mailing Address - Fax:
Practice Address - Street 1:16 FAYETTE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-1112
Practice Address - Country:US
Practice Address - Phone:617-497-9506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1022282104100000X
MA527106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP06611Medicare ID - Type Unspecified