Healthcare Provider Details

I. General information

NPI: 1518156900
Provider Name (Legal Business Name): MR. ALEX M KENNETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 08/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

634 PRESSLEY ST
SANTA ROSA CA
95404-5526
US

IV. Provider business mailing address

634 PRESSLEY ST
SANTA ROSA CA
95404-5526
US

V. Phone/Fax

Practice location:
  • Phone: 707-573-6955
  • Fax: 707-543-8176
Mailing address:
  • Phone: 707-573-6955
  • Fax: 707-543-8176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: