Provider Demographics
NPI:1093857757
Name:KENNEDY, RYAN PATRICK (MS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:PATRICK
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 S HARBOR BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-7937
Mailing Address - Country:US
Mailing Address - Phone:714-644-6480
Mailing Address - Fax:714-428-3477
Practice Address - Street 1:3601 S HARBOR BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-7937
Practice Address - Country:US
Practice Address - Phone:714-644-6480
Practice Address - Fax:714-428-3477
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50420101YM0800X, 225400000X
CAMFC 53770106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner