Provider Demographics
NPI:1316319304
Name:KENNEDY, VIRGINIA (LCSW)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 PEPPERS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-2070
Mailing Address - Country:US
Mailing Address - Phone:276-223-5441
Mailing Address - Fax:
Practice Address - Street 1:165 PEPPERS FERRY RD
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-2070
Practice Address - Country:US
Practice Address - Phone:276-223-5441
Practice Address - Fax:276-223-5454
Is Sole Proprietor?:No
Enumeration Date:2015-10-29
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040092051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0904009205OtherSOCIAL WORK LICENSE