Provider Demographics
NPI:1811543358
Name:KENNEDY, MARIE TYLA (BA PSYCH SC)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:TYLA
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:BA PSYCH SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056-2558
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-2558
Practice Address - Country:US
Practice Address - Phone:504-263-1403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator