Provider Demographics
NPI:1861094732
Name:KENNY, SUSAN (MFT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KENNY
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2553 TOPAZ DR
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-1564
Mailing Address - Country:US
Mailing Address - Phone:415-246-2804
Mailing Address - Fax:
Practice Address - Street 1:830 SWEETSER AVE
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-2462
Practice Address - Country:US
Practice Address - Phone:415-246-2804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-14
Last Update Date:2020-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA115472106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist