Provider Demographics
NPI:1386275568
Name:KENNEDY, RYAN PHILIP (CDCA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:PHILIP
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 E HUSTON ST
Mailing Address - Street 2:
Mailing Address - City:BARBERTON
Mailing Address - State:OH
Mailing Address - Zip Code:44203-3048
Mailing Address - Country:US
Mailing Address - Phone:440-668-1809
Mailing Address - Fax:
Practice Address - Street 1:396 E HUSTON ST
Practice Address - Street 2:
Practice Address - City:BARBERTON
Practice Address - State:OH
Practice Address - Zip Code:44203-3048
Practice Address - Country:US
Practice Address - Phone:440-668-1809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171226101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)