Provider Demographics
NPI:1699876920
Name:KENNEDY, TERRANCE HAROLD (LCSW)
Entity type:Individual
Prefix:
First Name:TERRANCE
Middle Name:HAROLD
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:TERRY
Other - Middle Name:
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:518 S SCHOOL ST
Mailing Address - Street 2:STE. 203
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-5479
Mailing Address - Country:US
Mailing Address - Phone:170-746-7136
Mailing Address - Fax:170-746-7136
Practice Address - Street 1:518 S SCHOOL ST
Practice Address - Street 2:STE. 203
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5479
Practice Address - Country:US
Practice Address - Phone:170-746-7136
Practice Address - Fax:170-746-7136
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS198691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ27118ZMedicare ID - Type UnspecifiedMEDICARE