Provider Demographics
NPI:1851162358
Name:HYDE, KENNEDY MARIE
Entity Type:Individual
Prefix:
First Name:KENNEDY
Middle Name:MARIE
Last Name:HYDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KENNEDY
Other - Middle Name:MARIE
Other - Last Name:HYDE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1424 S MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-4309
Mailing Address - Country:US
Mailing Address - Phone:517-312-1711
Mailing Address - Fax:
Practice Address - Street 1:1424 S MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-4309
Practice Address - Country:US
Practice Address - Phone:517-312-1711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician