Healthcare Provider Details

I. General information

NPI: 1912656646
Provider Name (Legal Business Name): ERIN KENNEDY APCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 03/21/2022
Certification Date: 03/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 MESA RIDGE RD APT 214
CARLSBAD CA
92010-6726
US

IV. Provider business mailing address

18226 VENTURA BLVD STE 202
TARZANA CA
91356-4246
US

V. Phone/Fax

Practice location:
  • Phone: 847-917-4790
  • Fax:
Mailing address:
  • Phone: 818-758-9450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10368
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: