Provider Demographics
NPI:1245255785
Name:KENNEDY, RICHARD T (PSYD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:T
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-4815
Mailing Address - Country:US
Mailing Address - Phone:360-740-8533
Mailing Address - Fax:360-740-8534
Practice Address - Street 1:57 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-4815
Practice Address - Country:US
Practice Address - Phone:360-740-8533
Practice Address - Fax:360-740-8534
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00001919103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAR49135Medicare UPIN
GAB15831Medicare PIN