Provider Demographics
NPI:1609530716
Name:KENNEDY, SARA RENEE (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:RENEE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 RIVERSIDE ST
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-1715
Mailing Address - Country:US
Mailing Address - Phone:320-515-1697
Mailing Address - Fax:
Practice Address - Street 1:105 UNION ST S STE 3
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1592
Practice Address - Country:US
Practice Address - Phone:651-448-2322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN186341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical