Provider Demographics
NPI:1780869669
Name:KENNEDY, SIOBHAN MELINDA (LMT)
Entity type:Individual
Prefix:
First Name:SIOBHAN
Middle Name:MELINDA
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3880 SE HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-5899
Mailing Address - Country:US
Mailing Address - Phone:503-513-4665
Mailing Address - Fax:503-513-4663
Practice Address - Street 1:3880 SE HARRISON ST
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-5899
Practice Address - Country:US
Practice Address - Phone:503-513-4665
Practice Address - Fax:503-513-4663
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12123174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist