Basic Information
| Provider Information | |||||||||
| NPI: | 1477800514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | GRAY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRAY | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2515 E NC HIGHWAY 54 | ||||||||
| Address2: | BLDG 2200 | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277135263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194930959 | ||||||||
| FaxNumber: | 9194930970 | ||||||||
| Practice Location | |||||||||
| Address1: | 2515 E NC HIGHWAY 54 | ||||||||
| Address2: | BULIDING 2200 | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277135263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194930959 | ||||||||
| FaxNumber: | 9194930970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2012 | ||||||||
| LastUpdateDate: | 05/19/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C009482 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.