Provider Demographics
NPI:1700411709
Name:KENNEDY, STACIE R (BSW)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:R
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 ELIDA RD
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45833-9056
Mailing Address - Country:US
Mailing Address - Phone:619-695-8010
Mailing Address - Fax:619-695-0004
Practice Address - Street 1:4615 HILTON CORPORATE DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-4151
Practice Address - Country:US
Practice Address - Phone:614-729-2024
Practice Address - Fax:614-729-2030
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty