Provider Demographics
NPI:1518641000
Name:KENNEDY-BUTLER, MATILDA ROSE
Entity Type:Individual
Prefix:
First Name:MATILDA
Middle Name:ROSE
Last Name:KENNEDY-BUTLER
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 1:10344 OLD OCEAN CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1162
Mailing Address - Country:US
Mailing Address - Phone:410-641-4582
Mailing Address - Fax:
Practice Address - Street 1:10344 OLD OCEAN CITY BLVD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-1162
Practice Address - Country:US
Practice Address - Phone:410-641-4582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01639237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter