Provider Demographics
NPI:1801321740
Name:KENNEDY, MYRNA ASTRAEA (MSABA, BCBA, LBA)
Entity type:Individual
Prefix:MRS
First Name:MYRNA
Middle Name:ASTRAEA
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MSABA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8019 NE 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-9604
Mailing Address - Country:US
Mailing Address - Phone:541-974-5778
Mailing Address - Fax:
Practice Address - Street 1:8019 NE 13TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-9604
Practice Address - Country:US
Practice Address - Phone:541-974-5778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-28
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABA61552219103K00000X, 103K00000X
WAAB61429916106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst