Basic Information
| Provider Information | |||||||||
| NPI: | 1699255729 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | H | ||||||||
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| Mailing Information | |||||||||
| Address1: | 69 DOVER RD | ||||||||
| Address2: | |||||||||
| City: | MILLIS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020541338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088010920 | ||||||||
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| Practice Location | |||||||||
| Address1: | 103 COMMERCIAL ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023023101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085804691 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2018 | ||||||||
| LastUpdateDate: | 09/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 414089 | MA | N | Behavioral Health & Social Service Providers | Social Worker | 172V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Community Health Worker |
No ID Information.