Provider Demographics
NPI:1871394502
Name:DOUGLAS, KENNEDY NICOLE DANIELLE
Entity type:Individual
Prefix:
First Name:KENNEDY
Middle Name:NICOLE DANIELLE
Last Name:DOUGLAS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16337 130TH AVE APT 13F
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-3035
Mailing Address - Country:US
Mailing Address - Phone:718-552-7006
Mailing Address - Fax:
Practice Address - Street 1:7000 AUSTIN STREET
Practice Address - Street 2:SUITE 402
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375
Practice Address - Country:US
Practice Address - Phone:718-762-7633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-19
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician