Provider Demographics
NPI:1285728550
Name:KENNEDY, THERESA ANN (BSW)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:ANN
Other - Last Name:LINNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSW
Mailing Address - Street 1:PO BOX 1356
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816-1356
Mailing Address - Country:US
Mailing Address - Phone:208-765-0955
Mailing Address - Fax:208-765-6972
Practice Address - Street 1:1115 IRONWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4936
Practice Address - Country:US
Practice Address - Phone:208-765-0955
Practice Address - Fax:208-765-6972
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW27132104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker