Provider Demographics
NPI:1760663041
Name:KENNEDY, KERT R (LCSW)
Entity type:Individual
Prefix:MR
First Name:KERT
Middle Name:R
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 1:223 N 3RD ST STE 210
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-6687
Mailing Address - Country:US
Mailing Address - Phone:918-910-0014
Mailing Address - Fax:888-519-9460
Practice Address - Street 1:223 N 3RD ST STE 210
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-6687
Practice Address - Country:US
Practice Address - Phone:918-910-0014
Practice Address - Fax:888-519-9460
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200364960AMedicaid