MEDICARE: DIANA LYNNE KENNEDY MSW,LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	5287-C	NV

General Provider Information

NPI Number	:	1417164401
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA LYNNE KENNEDY MSW,LCSW

Provider Business Mailing Address
First Line	:	2777 PARADISE RD
Second Line	:	SUITE 1404
City	:	LAS VEGAS
State	:	NV
Zip	:	89109
Country	:	US
Telephone Number	:	702-274-4116
Fax Number	:	702-434-6424

Provider Business Practice Location Address
First Line	:	4760 S PECOS RD
Second Line	:	SUITE 103 UNIT 14
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-6038
Country	:	US
Telephone Number	:	702-274-4116
Fax Number	:	702-434-6424

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	03/06/2015

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