Provider Demographics
NPI:1407184401
Name:DEXTER KENNICUTT, AMY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:
Last Name:DEXTER KENNICUTT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1172
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80160-1172
Mailing Address - Country:US
Mailing Address - Phone:970-368-5552
Mailing Address - Fax:
Practice Address - Street 1:5753 S PRINCE ST
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80120-1927
Practice Address - Country:US
Practice Address - Phone:970-368-5552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-02
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4953103TC0700X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical