Provider Demographics
NPI:1922986199
Name:KENNEDY, TATIANA MARIE
Entity type:Individual
Prefix:
First Name:TATIANA
Middle Name:MARIE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 W IVYWILD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-4514
Mailing Address - Country:US
Mailing Address - Phone:602-552-1514
Mailing Address - Fax:
Practice Address - Street 1:524 S 9TH AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-5075
Practice Address - Country:US
Practice Address - Phone:208-454-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-25
Last Update Date:2025-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker