Provider Demographics
NPI:1962782870
Name:KENNEDY, SHAWN M
Entity type:Individual
Prefix:MISS
First Name:SHAWN
Middle Name:M
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 1:504 MICAH DR
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-4720
Mailing Address - Country:US
Mailing Address - Phone:618-395-4306
Mailing Address - Fax:618-395-4507
Practice Address - Street 1:602 E 5TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT CARMEL
Practice Address - State:IL
Practice Address - Zip Code:62863-2152
Practice Address - Country:US
Practice Address - Phone:618-262-7473
Practice Address - Fax:618-262-8810
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor