Provider Demographics
NPI:1275851891
Name:KENNEDY-AMOS, DIANE NICOLE (LPC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:NICOLE
Last Name:KENNEDY-AMOS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 THOMAS JEFFERSON HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE COURT HOUSE
Mailing Address - State:VA
Mailing Address - Zip Code:23923-0340
Mailing Address - Country:US
Mailing Address - Phone:434-392-7049
Mailing Address - Fax:434-392-9221
Practice Address - Street 1:410 THOMAS JEFFERSON HIGHWAY
Practice Address - Street 2:
Practice Address - City:CHARLOTTE COURT HOUSE
Practice Address - State:VA
Practice Address - Zip Code:23923-0340
Practice Address - Country:US
Practice Address - Phone:434-392-7049
Practice Address - Fax:434-392-9221
Is Sole Proprietor?:No
Enumeration Date:2010-05-06
Last Update Date:2011-03-04
Deactivation Date:2010-05-11
Deactivation Code:
Reactivation Date:2011-03-04
Provider Licenses
StateLicense IDTaxonomies
VA0701004708103TC1900X
VA0812000549103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation