Provider Demographics
NPI:1548366396
Name:KENNELLY, SCOTT MICHAEL (LCSW)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:MICHAEL
Last Name:KENNELLY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 COHASSET RD STE 26
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-2260
Mailing Address - Country:US
Mailing Address - Phone:530-879-2945
Mailing Address - Fax:
Practice Address - Street 1:500 COHASSET RD STE 26
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-2260
Practice Address - Country:US
Practice Address - Phone:530-879-2945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA189961041C0700X
CAPPSC1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool