Provider Demographics
NPI:1841330784
Name:KENNEDY, WILLIAM T JR (LADC, PLMHP)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:T
Last Name:KENNEDY
Suffix:JR
Gender:M
Credentials:LADC, PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2616 W NORTH FRONT ST
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4234
Mailing Address - Country:US
Mailing Address - Phone:308-382-6575
Mailing Address - Fax:
Practice Address - Street 1:715 W ANNA ST
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68801-6713
Practice Address - Country:US
Practice Address - Phone:308-398-0350
Practice Address - Fax:308-398-0352
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NELADC-621101YA0400X
NE8362101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025551800Medicaid
NE98340OtherBLUECROSS BLUESHIELD
NELADC-621OtherLICENSE ALCOHOL DRUG COUN
NE600245205OtherMAGELLAN
NEPLMHP 8362OtherMENTAL HEALTH COUNSELOR