Provider Demographics
NPI:1952039125
Name:KENNEDY, SHELBY R
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:R
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-1943
Mailing Address - Country:US
Mailing Address - Phone:504-328-4245
Mailing Address - Fax:
Practice Address - Street 1:4600 RIVER RD
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-1943
Practice Address - Country:US
Practice Address - Phone:504-328-4245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1701033Medicaid