Provider Demographics
NPI:1861479636
Name:KENNEDY, MARY THERESA (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:THERESA
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:THERESA
Other - Last Name:REILLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:218-11 HORACE HARDING BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11364-2211
Mailing Address - Country:US
Mailing Address - Phone:718-631-8939
Mailing Address - Fax:
Practice Address - Street 1:217-04 NORTHERN BLVD
Practice Address - Street 2:STE 16
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3500
Practice Address - Country:US
Practice Address - Phone:718-631-8939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00760201103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01067481Medicaid
16174Medicare ID - Type Unspecified
NY01067481Medicaid