Provider Demographics
NPI:1881908226
Name:KENNEDY, TIANA SAMONE (LPC)
Entity type:Individual
Prefix:
First Name:TIANA
Middle Name:SAMONE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18632 APPOLINE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2335 BURTON ST SE STE 210
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4669
Practice Address - Country:US
Practice Address - Phone:616-236-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-27
Last Update Date:2025-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012015101Y00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health