Provider Demographics
NPI:1770825408
Name:KENNEDY, SHEALEEN MAIA (MED, BCBA, LBA)
Entity Type:Individual
Prefix:MS
First Name:SHEALEEN
Middle Name:MAIA
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4792
Mailing Address - Street 2:
Mailing Address - City:ROLLINGBAY
Mailing Address - State:WA
Mailing Address - Zip Code:98061-0792
Mailing Address - Country:US
Mailing Address - Phone:206-351-1811
Mailing Address - Fax:
Practice Address - Street 1:9431 COPPERTOP LOOP NE UNIT 205
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-3684
Practice Address - Country:US
Practice Address - Phone:206-351-1811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-20
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1-12-10437103K00000X
WABA603242577103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst