Provider Demographics
NPI:1902981624
Name:KENNEDY, CHARLES A (LCSW)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3104 E CAMELBACK RD # 721
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4502
Mailing Address - Country:US
Mailing Address - Phone:602-284-9343
Mailing Address - Fax:602-651-1043
Practice Address - Street 1:4120 N 20TH ST STE B
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-6022
Practice Address - Country:US
Practice Address - Phone:602-284-9343
Practice Address - Fax:602-651-1043
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6962-1231041C0700X
AZLCSW-124611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical