Provider Demographics
NPI:1578375192
Name:MONELLO, KENNEDY
Entity type:Individual
Prefix:
First Name:KENNEDY
Middle Name:
Last Name:MONELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2622 W CAMAS ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-2446
Mailing Address - Country:US
Mailing Address - Phone:503-754-8414
Mailing Address - Fax:
Practice Address - Street 1:2549 N STOKESBERRY PL
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-1144
Practice Address - Country:US
Practice Address - Phone:312-965-2997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician