Provider Demographics
NPI:1871925511
Name:KENNEDY, KIM (LCSW)
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:MOONAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:213 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:MC GREGOR
Mailing Address - State:TX
Mailing Address - Zip Code:76657-2328
Mailing Address - Country:US
Mailing Address - Phone:254-236-4158
Mailing Address - Fax:
Practice Address - Street 1:213 S MADISON ST
Practice Address - Street 2:
Practice Address - City:MC GREGOR
Practice Address - State:TX
Practice Address - Zip Code:76657-2328
Practice Address - Country:US
Practice Address - Phone:254-236-4158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-05
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10424139-35011041C0700X
CT50.0083661041C0700X
TX675621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT260022408OtherRAILROAD MEDICARE
UT876000308007Medicaid
UT000055266OtherMEDICARE PIN