Provider Demographics
NPI:1649483652
Name:KENNEDY-MCDONALD, KIM BEA (MA CCC-SP)
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:BEA
Last Name:KENNEDY-MCDONALD
Suffix:
Gender:F
Credentials:MA CCC-SP
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:BEA
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:131 ARCADIA RD
Mailing Address - Street 2:715 N BREWER
Mailing Address - City:VINITA
Mailing Address - State:OK
Mailing Address - Zip Code:74301-2710
Mailing Address - Country:US
Mailing Address - Phone:918-256-5644
Mailing Address - Fax:
Practice Address - Street 1:131 ARCADIA ROAD
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301-2710
Practice Address - Country:US
Practice Address - Phone:918-256-5644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK398235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist