Provider Demographics
NPI:1720205875
Name:KENNEDY, SUSAN LYNN (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LYNN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13213 W 21ST CT STE 104
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67235-9625
Mailing Address - Country:US
Mailing Address - Phone:316-573-6802
Mailing Address - Fax:316-721-2291
Practice Address - Street 1:13213 W 21ST CT STE 104
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67235-9625
Practice Address - Country:US
Practice Address - Phone:316-573-6802
Practice Address - Fax:316-721-2291
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2627235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS30004309950001Medicaid