Provider Demographics
NPI:1063190270
Name:KENNEDY, ELIZABETH MARIE (CCLS)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:CCLS
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:MARIE
Other - Last Name:CINCOTTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCLS
Mailing Address - Street 1:41714 GAWTHORPE LN
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-5850
Mailing Address - Country:US
Mailing Address - Phone:412-979-7953
Mailing Address - Fax:
Practice Address - Street 1:41714 GAWTHORPE LN
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-5850
Practice Address - Country:US
Practice Address - Phone:412-979-7953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA24887174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist