Provider Demographics
NPI:1356779912
Name:KENNEDY, JULIA MARIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:JULIA
Middle Name:MARIE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 FISCHER LN
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059-8203
Mailing Address - Country:US
Mailing Address - Phone:505-379-2709
Mailing Address - Fax:
Practice Address - Street 1:3939 SAN PEDRO DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-8900
Practice Address - Country:US
Practice Address - Phone:505-379-2709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-17
Last Update Date:2020-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1084103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM11703482OtherCAQH
NM11703482OtherCAQH