Provider Demographics
NPI:1144090036
Name:POWELL, KENNEDY (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KENNEDY
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 E 30TH ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-8805
Mailing Address - Country:US
Mailing Address - Phone:505-599-8617
Mailing Address - Fax:855-290-2205
Practice Address - Street 1:10074 TEN POINT RD
Practice Address - Street 2:
Practice Address - City:CANYON
Practice Address - State:TX
Practice Address - Zip Code:79015-4449
Practice Address - Country:US
Practice Address - Phone:806-690-4494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115850235Z00000X
NMSAH-2023-0236235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist