Provider Demographics
NPI:1619642485
Name:THOMPSON, KENNEDY
Entity Type:Individual
Prefix:MRS
First Name:KENNEDY
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KENNEDY
Other - Middle Name:
Other - Last Name:SHUELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7220 REDS RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OK
Mailing Address - Zip Code:73448-7285
Mailing Address - Country:US
Mailing Address - Phone:580-319-6537
Mailing Address - Fax:
Practice Address - Street 1:307 4TH AVE SE
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-8216
Practice Address - Country:US
Practice Address - Phone:580-300-3010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-12
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician