Provider Demographics
NPI:1538189774
Name:KENNELLY, KERRY ANN (PSYD)
Entity type:Individual
Prefix:DR
First Name:KERRY
Middle Name:ANN
Last Name:KENNELLY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2676 CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212-2669
Mailing Address - Country:US
Mailing Address - Phone:412-716-2078
Mailing Address - Fax:412-766-1731
Practice Address - Street 1:2676 CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15212-2669
Practice Address - Country:US
Practice Address - Phone:412-716-2078
Practice Address - Fax:412-766-1731
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS016023103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1015604510001Medicaid
PAP00290787OtherRAIL ROAD
PAP00290787OtherRAIL ROAD