MEDICARE: CATHLEEN ELIZABETH KENNEDY LPC

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	103TC1900X	Counseling Psychologist	LPC-21506	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LPC-20506	OTHER	AZ	LPC LICENSE.

General Provider Information

NPI Number	:	1982318200
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CATHLEEN ELIZABETH KENNEDY LPC

Provider Business Mailing Address
First Line	:	1760 E VILLA DR STE A
Second Line	:
City	:	COTTONWOOD
State	:	AZ
Zip	:	86326-4679
Country	:	US
Telephone Number	:	928-646-0347
Fax Number	:	928-646-7153

Provider Business Practice Location Address
First Line	:	1760 E VILLA DR STE A
Second Line	:
City	:	COTTONWOOD
State	:	AZ
Zip	:	86326-4679
Country	:	US
Telephone Number	:	928-646-0347
Fax Number	:	928-646-7153

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

Provider Enumeration Date	:	01/11/2023
Last Update Date	:	01/11/2023

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