Provider Demographics
NPI:1992750517
Name:KENNEDY, MARY KAY (MSW LCSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:KAY
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:KAY
Other - Last Name:EBNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:363 SOUTH HARLAN STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80226-3552
Mailing Address - Country:US
Mailing Address - Phone:303-217-5843
Mailing Address - Fax:303-922-7335
Practice Address - Street 1:363 SOUTH HARLAN STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80226-3552
Practice Address - Country:US
Practice Address - Phone:303-217-5843
Practice Address - Fax:303-922-7335
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLCSW9926641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
536498Medicare ID - Type Unspecified