Provider Demographics
NPI:1356726897
Name:KENNEDY, THOMAS
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3135 EUCLID AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-2524
Mailing Address - Country:US
Mailing Address - Phone:216-391-2030
Mailing Address - Fax:216-431-7189
Practice Address - Street 1:3135 EUCLID AVE STE 103
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2524
Practice Address - Country:US
Practice Address - Phone:216-391-2030
Practice Address - Fax:216-431-7189
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH981197101YA0400X
OH00222061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)