Provider Demographics
NPI:1053478768
Name:KRISTI KENNEN INC
Entity Type:Organization
Organization Name:KRISTI KENNEN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KENNEN
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:505-983-3676
Mailing Address - Street 1:1482B ST FRANCIS DR
Mailing Address - Street 2:ST FRANCIS PROF BLVD
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505
Mailing Address - Country:US
Mailing Address - Phone:505-830-1441
Mailing Address - Fax:505-883-8335
Practice Address - Street 1:1482B ST FRANCIS DR
Practice Address - Street 2:ST FRANCIS PROF BLVD
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-830-1441
Practice Address - Fax:505-883-8335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI1450104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
842608200Medicare ID - Type Unspecified