Basic Information
| Provider Information | |||||||||
| NPI: | 1447232483 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHEPHERD | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 121 CLEMENTS BRIDGE ROAD | ||||||||
| Address2: | |||||||||
| City: | BARRINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565461535 | ||||||||
| FaxNumber: | 8565466565 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 CLEMENTS BRIDGE ROAD | ||||||||
| Address2: | |||||||||
| City: | BARRINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565461535 | ||||||||
| FaxNumber: | 8565466565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 06/23/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 41YA00009600 | NJ | Y | Speech, Language and Hearing Service Providers | Audiologist | 237600000X | 25MG0004800 | NJ | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 875776 | 01 | HORIZON BCBSNJ | OTHER | 0991999000 | 01 | AMERIHEALTH | OTHER | 1827761 | 01 | CIGNA | OTHER | 557330 | 01 | AETNA | OTHER | 2975106 | 05 | NJ | MEDICAID | 462032 | 01 | MULTIPLAN | OTHER | P842947 | 01 | OXFORD UNITED HEALTHCARE | OTHER |