Provider Demographics
NPI:1164995825
Name:KENNEDY, VIRGILIA ELIZABETH (LCSW)
Entity Type:Individual
Prefix:
First Name:VIRGILIA
Middle Name:ELIZABETH
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 7842
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93456-7842
Mailing Address - Country:US
Mailing Address - Phone:805-765-2300
Mailing Address - Fax:
Practice Address - Street 1:1505 SHEPARD DRIVE
Practice Address - Street 2:SUITE 204
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454
Practice Address - Country:US
Practice Address - Phone:805-765-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-05
Last Update Date:2019-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW80556101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health