Provider Demographics
NPI:1306116066
Name:KENNEDY, MICHAEL SHAWN (SCHOOL PSYCHOLOGIST)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHAWN
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:SCHOOL PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 HAWKS DR
Mailing Address - Street 2:
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528
Mailing Address - Country:US
Mailing Address - Phone:575-759-3225
Mailing Address - Fax:575-759-3533
Practice Address - Street 1:113 HAWK DR
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528
Practice Address - Country:US
Practice Address - Phone:575-759-3225
Practice Address - Fax:575-759-3533
Is Sole Proprietor?:No
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM344005103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool