Provider Demographics
NPI:1720264336
Name:KENNEDY, MARY CAROL I (MSW, LCSW, CCS, LADC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CAROL
Last Name:KENNEDY
Suffix:I
Gender:F
Credentials:MSW, LCSW, CCS, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 SCAMMON ST
Mailing Address - Street 2:SUITE 19-181
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-5121
Mailing Address - Country:US
Mailing Address - Phone:207-284-1173
Mailing Address - Fax:
Practice Address - Street 1:23 WATER ST
Practice Address - Street 2:SUITE 7
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-5119
Practice Address - Country:US
Practice Address - Phone:207-284-1173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-14
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC3972101YA0400X
MELC49431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME200938OtherANTHEM
ME200938OtherANTHEM