Provider Demographics
NPI:1861989378
Name:KENNEDY, COLLEEN L (LICSW)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:L
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 S TOWER RD
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-5505
Mailing Address - Country:US
Mailing Address - Phone:218-736-6987
Mailing Address - Fax:218-736-6980
Practice Address - Street 1:980 S TOWER RD
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-5505
Practice Address - Country:US
Practice Address - Phone:218-736-6987
Practice Address - Fax:218-736-6980
Is Sole Proprietor?:No
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN250241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical