Provider Demographics
NPI:1881829232
Name:KENNEDY, ROSA LEE
Entity Type:Individual
Prefix:MRS
First Name:ROSA
Middle Name:LEE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 OAKFIELD SMYRNA RD
Mailing Address - Street 2:
Mailing Address - City:OAKFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04763-3033
Mailing Address - Country:US
Mailing Address - Phone:207-757-8796
Mailing Address - Fax:
Practice Address - Street 1:375 OAKFIELD SMYRNA RD
Practice Address - Street 2:
Practice Address - City:OAKFIELD
Practice Address - State:ME
Practice Address - Zip Code:04763-3033
Practice Address - Country:US
Practice Address - Phone:207-757-8796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-28
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME43279700Medicaid