Provider Demographics
NPI:1659858686
Name:KENNEDY, SUSAN EMILY
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:EMILY
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 1:304 E PINE ST # 19
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-4969
Mailing Address - Country:US
Mailing Address - Phone:863-614-0048
Mailing Address - Fax:863-279-1204
Practice Address - Street 1:304 E PINE ST # 19
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-4969
Practice Address - Country:US
Practice Address - Phone:863-614-0048
Practice Address - Fax:863-279-1204
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-16-16370103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023072500Medicaid