Provider Demographics
NPI:1851546972
Name:KENNELLY, SUSAN KAY (MSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KAY
Last Name:KENNELLY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-1939
Mailing Address - Country:US
Mailing Address - Phone:612-752-8240
Mailing Address - Fax:612-752-8201
Practice Address - Street 1:1825 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-1939
Practice Address - Country:US
Practice Address - Phone:612-752-8240
Practice Address - Fax:612-752-8201
Is Sole Proprietor?:No
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical