Healthcare Provider Details

I. General information

NPI: 1093857757
Provider Name (Legal Business Name): RYAN PATRICK KENNEDY M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 12/27/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 S HARBOR BLVD STE 100
SANTA ANA CA
92704-7937
US

IV. Provider business mailing address

3601 S HARBOR BLVD STE 100
SANTA ANA CA
92704-7937
US

V. Phone/Fax

Practice location:
  • Phone: 714-644-6480
  • Fax: 714-428-3477
Mailing address:
  • Phone: 714-644-6480
  • Fax: 714-428-3477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number50420
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number50420
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 53770
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: