Provider Demographics
NPI:1801103106
Name:KENNEDY, BRENDAN CHARLES (CADC II, BS)
Entity type:Individual
Prefix:MR
First Name:BRENDAN
Middle Name:CHARLES
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:CADC II, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3793 RIVER RD N
Mailing Address - Street 2:SUITE A
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-4827
Mailing Address - Country:US
Mailing Address - Phone:503-304-7002
Mailing Address - Fax:503-304-7049
Practice Address - Street 1:3793 RIVER RD N
Practice Address - Street 2:SUITE A
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4827
Practice Address - Country:US
Practice Address - Phone:503-304-7002
Practice Address - Fax:503-304-7049
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4150510000101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR4150150000Medicaid