Provider Demographics
NPI:1881100303
Name:KENNEDY, CASEY JO (RBT-17-46255)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:JO
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:RBT-17-46255
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11447 J HILL RD
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66441-7899
Mailing Address - Country:US
Mailing Address - Phone:402-460-0010
Mailing Address - Fax:
Practice Address - Street 1:2715 INDUSTRIAL ST
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:KS
Practice Address - Zip Code:66441-8398
Practice Address - Country:US
Practice Address - Phone:785-256-9096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSRBT-17-46255106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSRBT-17-46255OtherTRICARE