Provider Demographics
NPI:1588687693
Name:KENNEDY, IRENE VANDEETER (LCSW)
Entity type:Individual
Prefix:MS
First Name:IRENE
Middle Name:VANDEETER
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3716 NATIONAL DR
Mailing Address - Street 2:SUITE 224
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-4068
Mailing Address - Country:US
Mailing Address - Phone:919-571-2671
Mailing Address - Fax:919-571-2721
Practice Address - Street 1:3716 NATIONAL DR
Practice Address - Street 2:SUITE 224
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-4068
Practice Address - Country:US
Practice Address - Phone:919-571-2671
Practice Address - Fax:919-571-2721
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0021361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC48593OtherBLUE CROSS BLUE SHIELD
2867296Medicare ID - Type Unspecified