Provider Demographics
NPI:1083179410
Name:KENNEDY, MARILYN (MA-COUNSELING)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MA-COUNSELING
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 CARVER ST
Mailing Address - Street 2:
Mailing Address - City:DUE WEST
Mailing Address - State:SC
Mailing Address - Zip Code:29639-9583
Mailing Address - Country:US
Mailing Address - Phone:864-376-9281
Mailing Address - Fax:
Practice Address - Street 1:17 MEMORIAL MEDICAL DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4407
Practice Address - Country:US
Practice Address - Phone:864-283-0637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7074101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional