Provider Demographics
NPI:1902554694
Name:KENNISON, LORI L (LMHC, MAC, MCAP, CRC)
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:L
Last Name:KENNISON
Suffix:
Gender:F
Credentials:LMHC, MAC, MCAP, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:768 89TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-3014
Mailing Address - Country:US
Mailing Address - Phone:727-560-7632
Mailing Address - Fax:
Practice Address - Street 1:2750 N MCMULLEN BOOTH RD STE 102A
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-3362
Practice Address - Country:US
Practice Address - Phone:727-560-7632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-12
Last Update Date:2022-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH15343101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional