Provider Demographics
NPI:1689141103
Name:KENNEDY, VIRGINIA MAE (CDPT)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:MAE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 HARRISON AVE APT E116
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-4525
Mailing Address - Country:US
Mailing Address - Phone:360-270-3115
Mailing Address - Fax:
Practice Address - Street 1:12200 BORDEAUX RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:WA
Practice Address - Zip Code:98556
Practice Address - Country:US
Practice Address - Phone:360-359-4075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60537602101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)