Healthcare Provider Details

I. General information

NPI: 1376164269
Provider Name (Legal Business Name): ROXANA SHOHREH KENNEDY LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2020
Last Update Date: 01/14/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4135 DIXIE HWY
ELSMERE KY
41018-1815
US

IV. Provider business mailing address

615 ELSINORE PL STE 200
CINCINNATI OH
45202-1457
US

V. Phone/Fax

Practice location:
  • Phone: 833-510-4357
  • Fax: 866-460-2997
Mailing address:
  • Phone: 833-510-4357
  • Fax: 866-460-2997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS.2106606
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number246171
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number256021
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: