Provider Demographics
NPI:1013626035
Name:KENNEDY, ALEXANDRA JANE (LCSW)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:JANE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:JANE
Other - Last Name:WHEELER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16 ISLAND HILL AVE UNIT 104
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-6141
Mailing Address - Country:US
Mailing Address - Phone:413-464-3067
Mailing Address - Fax:
Practice Address - Street 1:47 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4728
Practice Address - Country:US
Practice Address - Phone:413-464-3067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2287561041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical