Provider Demographics
NPI:1861901126
Name:KENNEDY, MYLES (LMHC)
Entity type:Individual
Prefix:
First Name:MYLES
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-4337
Mailing Address - Country:US
Mailing Address - Phone:508-742-5508
Mailing Address - Fax:
Practice Address - Street 1:258 ADAMS ST
Practice Address - Street 2:
Practice Address - City:FAIRHAVEN
Practice Address - State:MA
Practice Address - Zip Code:02719-4337
Practice Address - Country:US
Practice Address - Phone:508-742-5508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-29
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MALMHC12471101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health