Provider Demographics
NPI:1871834374
Name:KENNEDY, KATHERINE E (CSW, MS, SAC-IT)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:E
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:CSW, MS, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9433 COUNTY RD J
Mailing Address - Street 2:
Mailing Address - City:MINOCQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54548-9318
Mailing Address - Country:US
Mailing Address - Phone:715-356-5377
Mailing Address - Fax:715-356-5378
Practice Address - Street 1:9433 COUNTY RD J
Practice Address - Street 2:
Practice Address - City:MINOCQUA
Practice Address - State:WI
Practice Address - Zip Code:54548-9318
Practice Address - Country:US
Practice Address - Phone:715-356-5377
Practice Address - Fax:715-356-5378
Is Sole Proprietor?:No
Enumeration Date:2013-03-07
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16533-130101YA0400X
WI9677-120104100000X
WI1712-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker