Provider Demographics
NPI:1528755337
Name:KENNEDY, NICOLE KATELYN (LMFT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:KATELYN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:KATELYN
Other - Last Name:MACINTYRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1002 12TH ST APT 201
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-6425
Mailing Address - Country:US
Mailing Address - Phone:240-481-7513
Mailing Address - Fax:
Practice Address - Street 1:1002 12TH ST APT 201
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-6425
Practice Address - Country:US
Practice Address - Phone:240-481-7513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132688106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist