Provider Demographics
NPI:1023491743
Name:KENNEDY, MICHAEL (PHD, ARNP)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:PHD, ARNP
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:GLENN
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD, ARNP
Mailing Address - Street 1:PO BOX 1275
Mailing Address - Street 2:251 EAST NORTHCREST DRIVE
Mailing Address - City:ALLYN
Mailing Address - State:WA
Mailing Address - Zip Code:98524-1275
Mailing Address - Country:US
Mailing Address - Phone:360-990-6796
Mailing Address - Fax:
Practice Address - Street 1:1116 SUMMIT AVE
Practice Address - Street 2:THERAPEUTIC HEALTH SERVICES
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2831
Practice Address - Country:US
Practice Address - Phone:206-323-0930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00087927163W00000X
WAAP30002443364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No163W00000XNursing Service ProvidersRegistered Nurse