Provider Demographics
NPI:1568635738
Name:KENNEDY, MARY A (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 ALFRESCO PL
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-1807
Mailing Address - Country:US
Mailing Address - Phone:502-295-6034
Mailing Address - Fax:502-459-4362
Practice Address - Street 1:1801 ALFRESCO PL
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-1807
Practice Address - Country:US
Practice Address - Phone:502-295-6034
Practice Address - Fax:502-459-4362
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2014-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2167235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2167OtherLICENSE