Healthcare Provider Details

I. General information

NPI: 1083564207
Provider Name (Legal Business Name): ELIZABETH KENNEDY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2026
Last Update Date: 01/28/2026
Certification Date: 01/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 HARRIMAN LN APT C
REDONDO BEACH CA
90278-4158
US

IV. Provider business mailing address

1725 HARRIMAN LN APT C
REDONDO BEACH CA
90278-4158
US

V. Phone/Fax

Practice location:
  • Phone: 714-397-2508
  • Fax:
Mailing address:
  • Phone: 714-397-2508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number128216
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: