Provider Demographics
NPI:1386779346
Name:KENNEDY, MITCH L (ND)
Entity type:Individual
Prefix:DR
First Name:MITCH
Middle Name:L
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 ARCH RD
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-4206
Mailing Address - Country:US
Mailing Address - Phone:860-712-4792
Mailing Address - Fax:
Practice Address - Street 1:46 W AVON RD
Practice Address - Street 2:SUITE 202
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3679
Practice Address - Country:US
Practice Address - Phone:860-673-9954
Practice Address - Fax:860-673-4063
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000245175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000245OtherSTATE OF CT LICENSE NO.