Healthcare Provider Details

I. General information

NPI: 1174844518
Provider Name (Legal Business Name): COLLEEN HENNESSY M.S., L.P.C.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 10/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 GATEWAY CENTER WAY SUITE 300
SAN DIEGO CA
92102-4500
US

IV. Provider business mailing address

1202 MORENA BLVD STE 203
SAN DIEGO CA
92110-3843
US

V. Phone/Fax

Practice location:
  • Phone: 619-398-2156
  • Fax:
Mailing address:
  • Phone: 619-398-3261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number286
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number286
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: