Provider Demographics
NPI:1134579469
Name:KENNEDY, CRYSTAL MARIE (MBA)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MARIE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4210 S 1180 E
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:IN
Mailing Address - Zip Code:46747-9660
Mailing Address - Country:US
Mailing Address - Phone:463-203-7019
Mailing Address - Fax:
Practice Address - Street 1:7 VINE ST
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:IN
Practice Address - Zip Code:46017-1618
Practice Address - Country:US
Practice Address - Phone:765-639-7604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-17
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No104100000XBehavioral Health & Social Service ProvidersSocial Worker