Provider Demographics
NPI:1790149672
Name:KENNEDY, SHEILA (CAADAC II)
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:CAADAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1628 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-2405
Mailing Address - Country:US
Mailing Address - Phone:707-649-8300
Mailing Address - Fax:707-649-8302
Practice Address - Street 1:1628 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-2405
Practice Address - Country:US
Practice Address - Phone:707-649-8300
Practice Address - Fax:707-649-8302
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-07
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA08660315101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)