Provider Demographics
NPI:1639329410
Name:KENNEDY, WENDY (MA)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 W AERO DR
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-5407
Mailing Address - Country:US
Mailing Address - Phone:928-474-3303
Mailing Address - Fax:
Practice Address - Street 1:3450 N 3RD ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2331
Practice Address - Country:US
Practice Address - Phone:602-265-8338
Practice Address - Fax:602-265-8574
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-0037101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLPC-0037OtherSTATE