Provider Demographics
NPI:1801490644
Name:KENNEDY, SHELLEY (LMSW)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5962 HILLANDALE RD
Mailing Address - Street 2:
Mailing Address - City:SODUS
Mailing Address - State:MI
Mailing Address - Zip Code:49126-9745
Mailing Address - Country:US
Mailing Address - Phone:559-560-8090
Mailing Address - Fax:
Practice Address - Street 1:7085 TERRITORIAL RD
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-9458
Practice Address - Country:US
Practice Address - Phone:559-560-8090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011034891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical