Provider Demographics
NPI:1013073527
Name:KENNEDY, MICHELLE L (MSW-CSW-QMHP)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:L
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MSW-CSW-QMHP
Other - Prefix:MS
Other - First Name:MIKKI
Other - Middle Name:
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW-CSW-QMHP
Mailing Address - Street 1:P.O. BOX 447
Mailing Address - Street 2:
Mailing Address - City:LEMMON
Mailing Address - State:SD
Mailing Address - Zip Code:57638-0447
Mailing Address - Country:US
Mailing Address - Phone:605-374-3862
Mailing Address - Fax:605-374-3864
Practice Address - Street 1:11 EAST 4TH STREET
Practice Address - Street 2:
Practice Address - City:LEMMON
Practice Address - State:SD
Practice Address - Zip Code:57638-0447
Practice Address - Country:US
Practice Address - Phone:605-374-3862
Practice Address - Fax:605-374-3864
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1948101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0003226OtherBCBS THREE RIVERS GROUP #
SD4994184OtherBCBS PROVIDER #