Provider Demographics
NPI:1578335204
Name:KENNEDY, MICHELLE KATHRYN
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:KATHRYN
Last Name:KENNEDY
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 1:13945 W ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-4506
Mailing Address - Country:US
Mailing Address - Phone:720-382-9558
Mailing Address - Fax:
Practice Address - Street 1:13945 W ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-4506
Practice Address - Country:US
Practice Address - Phone:720-382-9558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00099238441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical