Provider Demographics
NPI:1871089177
Name:KENNEDY, MELISSA JO (MED)
Entity type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:JO
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4112 ULSTER RD
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-2867
Mailing Address - Country:US
Mailing Address - Phone:301-661-0505
Mailing Address - Fax:
Practice Address - Street 1:8815 COLUMBIA PARKWAY
Practice Address - Street 2:4
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045
Practice Address - Country:US
Practice Address - Phone:877-776-8502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician