MEDICARE: KENDRA KIRSONIS MA, LMFTA, LMHCA

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	106H00000X	Marriage & Family Therapist	MG60908615	WA
2	101YM0800X	Mental Health Counselor	MC60908687	WA

General Provider Information

NPI Number	:	1740846286
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENDRA KIRSONIS MA, LMFTA, LMHCA

Provider Business Mailing Address
First Line	:	PO BOX 70111
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98127-0111
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5424 BALLARD AVE NW STE 300
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98107-4046
Country	:	US
Telephone Number	:	747-228-2840
Fax Number	:

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

Provider Enumeration Date	:	05/09/2019
Last Update Date	:	05/09/2019

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