Provider Demographics
NPI:1689126245
Name:KENNEDY, CASSONDRE (BA)
Entity Type:Individual
Prefix:
First Name:CASSONDRE
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4083 CLOUD SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:RINGGOLD
Mailing Address - State:GA
Mailing Address - Zip Code:30736-8411
Mailing Address - Country:US
Mailing Address - Phone:706-820-6087
Mailing Address - Fax:
Practice Address - Street 1:4083 CLOUD SPRINGS RD
Practice Address - Street 2:
Practice Address - City:RINGGOLD
Practice Address - State:GA
Practice Address - Zip Code:30736-8411
Practice Address - Country:US
Practice Address - Phone:706-820-6087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)