Provider Demographics
NPI:1750485116
Name:KENNEDY, CHARLES REED (PH D)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:REED
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 HOLLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208
Mailing Address - Country:US
Mailing Address - Phone:518-626-5000
Mailing Address - Fax:
Practice Address - Street 1:112 HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3404
Practice Address - Country:US
Practice Address - Phone:518-626-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013371-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical