Provider Demographics
NPI:1730490574
Name:MARY M. KENNEDY, PSYD LLC
Entity Type:Organization
Organization Name:MARY M. KENNEDY, PSYD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:MARCELLYN
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD HSPP
Authorized Official - Phone:219-464-9000
Mailing Address - Street 1:7 NAPOLEON ST
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-4725
Mailing Address - Country:US
Mailing Address - Phone:219-464-9000
Mailing Address - Fax:219-462-5128
Practice Address - Street 1:7 NAPOLEON ST
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-4725
Practice Address - Country:US
Practice Address - Phone:219-464-9000
Practice Address - Fax:219-462-5128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-26
Last Update Date:2010-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042264A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty