MEDICARE: REBECCA KENNEDY

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	101YM0800X	Mental Health Counselor
2	390200000X	Student in an Organized Health Care Education/Training Program
3	1041C0700X	Clinical Social Worker	95510	CA

General Provider Information

NPI Number	:	1629525464
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA KENNEDY

Provider Business Mailing Address
First Line	:	3435 OCEAN PARK BLVD STE 207
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90405-3314
Country	:	US
Telephone Number	:	323-895-3139
Fax Number	:

Provider Business Practice Location Address
First Line	:	3435 OCEAN PARK BLVD STE 207
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90405-3314
Country	:	US
Telephone Number	:	323-895-3139
Fax Number	:

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

Provider Enumeration Date	:	09/09/2016
Last Update Date	:	08/14/2020

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