Provider Demographics
NPI:1427695212
Name:KENNEDY, CYNTHIA MARIE (RBT)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:MARIE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22712 VISTAWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-5501
Mailing Address - Country:US
Mailing Address - Phone:561-716-1414
Mailing Address - Fax:
Practice Address - Street 1:5180 W ATLANTIC AVE STE 112
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-8103
Practice Address - Country:US
Practice Address - Phone:561-674-9996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-29
Last Update Date:2019-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-94926106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106S00000XMedicaid