Provider Demographics
NPI:1760134001
Name:KENNEY, MICHELE RENAE
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:RENAE
Last Name:KENNEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6910 N MAIN ST UNIT 13D
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-9681
Mailing Address - Country:US
Mailing Address - Phone:269-240-3343
Mailing Address - Fax:
Practice Address - Street 1:6910 N MAIN ST UNIT 13D
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-9681
Practice Address - Country:US
Practice Address - Phone:269-240-3343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-18
Last Update Date:2022-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN85000400A106H00000X
IN35002274A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist