Provider Demographics
NPI:1639420698
Name:KENNEDY, MEGAN MARY
Entity type:Individual
Prefix:MS
First Name:MEGAN
Middle Name:MARY
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2948 N 74TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-1012
Mailing Address - Country:US
Mailing Address - Phone:414-774-0764
Mailing Address - Fax:
Practice Address - Street 1:2948 N 74TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1012
Practice Address - Country:US
Practice Address - Phone:414-774-0764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-30
Last Update Date:2012-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2095-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist