Provider Demographics
NPI:1891130480
Name:KENNEDY, TRACI MICHELLE (PHD)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:MICHELLE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3811 OHARA ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213-2561
Mailing Address - Country:US
Mailing Address - Phone:412-246-6087
Mailing Address - Fax:
Practice Address - Street 1:3811 OHARA ST
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-2561
Practice Address - Country:US
Practice Address - Phone:412-246-6087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-08
Last Update Date:2021-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC2200X
PAPS017718103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent