Provider Demographics
NPI:1790830610
Name:KENNEDY, TIMOTHY ALAN (PHD, LISW)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:ALAN
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:PHD, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9468 CHESHIRE RD
Mailing Address - Street 2:
Mailing Address - City:SUNBURY
Mailing Address - State:OH
Mailing Address - Zip Code:43074-9543
Mailing Address - Country:US
Mailing Address - Phone:740-965-2145
Mailing Address - Fax:
Practice Address - Street 1:6827 N HIGH ST
Practice Address - Street 2:121
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-2517
Practice Address - Country:US
Practice Address - Phone:614-436-5070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-4921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHKESW03991Medicare ID - Type Unspecified