Provider Demographics
NPI:1871478891
Name:KENNEDY, MIA (PHD, LCMHCA (NC))
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PHD, LCMHCA (NC)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6008
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27519-1002
Mailing Address - Country:US
Mailing Address - Phone:984-208-6008
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 6008
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27519-1002
Practice Address - Country:US
Practice Address - Phone:984-208-6008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-08
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19427101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health