Provider Demographics
NPI:1003582305
Name:SOUZA, KENNIDY RAE
Entity Type:Individual
Prefix:
First Name:KENNIDY
Middle Name:RAE
Last Name:SOUZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6374 NEWTOWN DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43231-7602
Mailing Address - Country:US
Mailing Address - Phone:703-362-9598
Mailing Address - Fax:
Practice Address - Street 1:5548 HILLIARD ROME OFFICE PARK
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026-7286
Practice Address - Country:US
Practice Address - Phone:740-845-8652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2103297-TRNE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health