Provider Demographics
NPI:1336856210
Name:KENNEDY, CHARLES ANDREW (ASW)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ANDREW
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:GUERNEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95446-1449
Mailing Address - Country:US
Mailing Address - Phone:707-326-1425
Mailing Address - Fax:
Practice Address - Street 1:16387 FIRST STREET
Practice Address - Street 2:
Practice Address - City:GUERNEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95446-9544
Practice Address - Country:US
Practice Address - Phone:707-326-1452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109436104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker