Provider Demographics
NPI:1902267172
Name:KENNEDY, CAITLYN JUSTINE (LSW, BSSW)
Entity type:Individual
Prefix:
First Name:CAITLYN
Middle Name:JUSTINE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LSW, BSSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 MOXAHALA AVE
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701
Mailing Address - Country:US
Mailing Address - Phone:888-204-4207
Mailing Address - Fax:
Practice Address - Street 1:405 MOXAHALA AVE
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-4915
Practice Address - Country:US
Practice Address - Phone:888-204-4207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1500653104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker