Healthcare Provider Details

I. General information

NPI: 1497549737
Provider Name (Legal Business Name): KENNEDY HUTTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2025
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8526 HICKORY LN
RIVERSIDE CA
92504-2915
US

IV. Provider business mailing address

16950 JASMINE ST APT 35
VICTORVILLE CA
92395-5705
US

V. Phone/Fax

Practice location:
  • Phone: 951-706-0028
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: