Provider Demographics
NPI:1992364202
Name:KENNEDY-REA, JULIE LYNN
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:LYNN
Last Name:KENNEDY-REA
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 1:3245 MOUNT CLARE RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-7458
Mailing Address - Country:US
Mailing Address - Phone:304-677-8564
Mailing Address - Fax:
Practice Address - Street 1:27 TROVATO ST STE 103
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-7286
Practice Address - Country:US
Practice Address - Phone:304-623-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1093101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional