Provider Demographics
NPI:1457503633
Name:KENNEDY, ANN M (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:M
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 PROCTOR RD
Mailing Address - Street 2:
Mailing Address - City:CHENANGO FORKS
Mailing Address - State:NY
Mailing Address - Zip Code:13746-2143
Mailing Address - Country:US
Mailing Address - Phone:607-656-4787
Mailing Address - Fax:
Practice Address - Street 1:171 PROCTOR RD
Practice Address - Street 2:
Practice Address - City:CHENANGO FORKS
Practice Address - State:NY
Practice Address - Zip Code:13746-2143
Practice Address - Country:US
Practice Address - Phone:607-237-2896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-19
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012992-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY012992-1OtherSTATE LICENSURE