Healthcare Provider Details

I. General information

NPI: 1992160253
Provider Name (Legal Business Name): ELIZABETH ANNE KENNEDY MA, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2015
Last Update Date: 09/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5638 PROFESSIONAL CIR
INDIANAPOLIS IN
46241
US

IV. Provider business mailing address

5101 E US HIGHWAY 36 STE 100
AVON IN
46123-6646
US

V. Phone/Fax

Practice location:
  • Phone: 317-247-8919
  • Fax:
Mailing address:
  • Phone: 888-714-1927
  • Fax: 317-745-9565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39003259A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: