Provider Demographics
NPI:1891864328
Name:KENNEDY, MARK (SOCIAL WORKER II)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:SOCIAL WORKER II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1614 JASON COURT
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374
Mailing Address - Country:US
Mailing Address - Phone:626-347-0539
Mailing Address - Fax:
Practice Address - Street 1:658 E BRIER DRIVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415
Practice Address - Country:US
Practice Address - Phone:909-501-0764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health