Provider Demographics
NPI:1942379888
Name:KENNEDY, HEATHER JEAN HART (MSW LCSW)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:JEAN HART
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:JEAN
Other - Last Name:HART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:W9203 BLUE SPRUCE LANE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:WI
Mailing Address - Zip Code:53523
Mailing Address - Country:US
Mailing Address - Phone:608-423-3960
Mailing Address - Fax:608-423-7166
Practice Address - Street 1:817 N MARSHALL ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202
Practice Address - Country:US
Practice Address - Phone:414-224-0800
Practice Address - Fax:414-224-0883
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69191231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40945400Medicaid
WI04506006Medicare ID - Type Unspecified