Provider Demographics
NPI:1285709352
Name:KENNEDY, CAROLINE AMY (LSW)
Entity type:Individual
Prefix:MRS
First Name:CAROLINE
Middle Name:AMY
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 BRENTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-1333
Mailing Address - Country:US
Mailing Address - Phone:952-837-8991
Mailing Address - Fax:
Practice Address - Street 1:7250 FRANCE AVE S STE 111
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4311
Practice Address - Country:US
Practice Address - Phone:952-837-8991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN264171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator