Provider Demographics
NPI:1689215816
Name:KENNEDY, ANNA ROSE I (N/A)
Entity Type:Individual
Prefix:MS
First Name:ANNA
Middle Name:ROSE
Last Name:KENNEDY
Suffix:I
Gender:F
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2775 E LANSING DR
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-7755
Mailing Address - Country:US
Mailing Address - Phone:616-301-8000
Mailing Address - Fax:
Practice Address - Street 1:2814 WOODCLIFF CIR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-3155
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-29
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician