Provider Demographics
NPI:1063571537
Name:KENNEDY, JOHN R II (MSW, LISW-CP)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:KENNEDY
Suffix:II
Gender:M
Credentials:MSW, LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 SAINT ANDREWS RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-5816
Mailing Address - Country:US
Mailing Address - Phone:803-731-4708
Mailing Address - Fax:803-612-1206
Practice Address - Street 1:900 SAINT ANDREWS RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-5816
Practice Address - Country:US
Practice Address - Phone:803-731-4708
Practice Address - Fax:803-612-1206
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ355378233Medicare PIN