Healthcare Provider Details

I. General information

NPI: 1205962255
Provider Name (Legal Business Name): PATRICIA KENNEDY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 01/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9374 OLIVETTE STREET
OLIVETTE MO
63132-3253
US

IV. Provider business mailing address

9374 OLIVE STREET
OLIVETTE MO
63132-3253
US

V. Phone/Fax

Practice location:
  • Phone: 314-490-4141
  • Fax: 314-962-4894
Mailing address:
  • Phone: 314-490-4141
  • Fax: 314-962-4894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number001239
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number300064
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: