Healthcare Provider Details

I. General information

NPI: 1043461007
Provider Name (Legal Business Name): MARY PANAHI KENNEDY MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 09/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N BROOKHURST ST #320
ANAHEIM CA
92801-5226
US

IV. Provider business mailing address

PO BOX 8933
BREA CA
92822-5933
US

V. Phone/Fax

Practice location:
  • Phone: 714-490-7711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: