Provider Demographics
NPI:1609467414
Name:KENNEDY, RAYMOND VERNON
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:VERNON
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 S COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-3605
Mailing Address - Country:US
Mailing Address - Phone:601-906-6742
Mailing Address - Fax:
Practice Address - Street 1:721 S COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-3605
Practice Address - Country:US
Practice Address - Phone:601-906-6742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP-0585101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP-0585OtherSTATE LICENSE NUMBER LPC