Healthcare Provider Details

I. General information

NPI: 1629903679
Provider Name (Legal Business Name): KENNEDI PAUL LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13477 W BLUEBONNET DR
BOISE ID
83713-1341
US

IV. Provider business mailing address

10549 N CAYUSE WAY
BOISE ID
83714-9723
US

V. Phone/Fax

Practice location:
  • Phone: 208-254-1112
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8481717
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: