Provider Demographics
NPI:1972563757
Name:KENNEDY, MARY M (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:M
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:S
Other - Last Name:MILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 51322
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-5622
Mailing Address - Country:US
Mailing Address - Phone:270-843-5300
Mailing Address - Fax:270-843-5383
Practice Address - Street 1:181 W PROFESSIONAL PARK CT
Practice Address - Street 2:SUITE 1
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3250
Practice Address - Country:US
Practice Address - Phone:270-843-5300
Practice Address - Fax:270-843-5383
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY13281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical