Provider Demographics
NPI:1992161673
Name:KENNEDY, ELIZABETH J (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:J
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1931 BLACK ROCK TPKE
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-3506
Mailing Address - Country:US
Mailing Address - Phone:203-332-4363
Mailing Address - Fax:203-330-6761
Practice Address - Street 1:1931 BLACK ROCK TPKE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-3506
Practice Address - Country:US
Practice Address - Phone:203-384-8681
Practice Address - Fax:203-384-0722
Is Sole Proprietor?:No
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005067235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist