Provider Demographics
NPI:1073356697
Name:KENNEDY, SALEM RAY
Entity type:Individual
Prefix:
First Name:SALEM
Middle Name:RAY
Last Name:KENNEDY
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 MARKET WAY
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:GA
Mailing Address - Zip Code:30549-2290
Mailing Address - Country:US
Mailing Address - Phone:770-906-3427
Mailing Address - Fax:
Practice Address - Street 1:1130 HURRICANE SHOALS RD NE
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-4851
Practice Address - Country:US
Practice Address - Phone:404-740-0355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician