1225576051 NPI number — BETH KENNEDY BCBA

Table of content: BETH KENNEDY BCBA (NPI 1225576051)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225576051 NPI number — BETH KENNEDY BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENNEDY
Provider First Name:
BETH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225576051
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
157 CHURCH ST
Provider Second Line Business Mailing Address:
19TH FLOOR
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06510-2100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-261-1110
Provider Business Mailing Address Fax Number:
866-696-7991

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
157 CHURCH ST
Provider Second Line Business Practice Location Address:
19TH FLOOR
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06510-2100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-261-1110
Provider Business Practice Location Address Fax Number:
866-696-7991
Provider Enumeration Date:
01/31/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-16-23983 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)