Basic Information
| Provider Information | |||||||||
| NPI: | 1689042749 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1836 FREMONT ST | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975202537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414825792 | ||||||||
| FaxNumber: | 5414825034 | ||||||||
| Practice Location | |||||||||
| Address1: | 1836 FREMONT ST | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975202537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414825792 | ||||||||
| FaxNumber: | 5414825034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2015 | ||||||||
| LastUpdateDate: | 09/07/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.