Provider Demographics
NPI:1417164401
Name:KENNEDY, DIANA LYNNE (MSW,LCSW)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LYNNE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MSW,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2777 PARADISE RD
Mailing Address - Street 2:SUITE 1404
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109
Mailing Address - Country:US
Mailing Address - Phone:702-274-4116
Mailing Address - Fax:702-434-6424
Practice Address - Street 1:4760 S PECOS RD
Practice Address - Street 2:SUITE 103 UNIT 14
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-6038
Practice Address - Country:US
Practice Address - Phone:702-274-4116
Practice Address - Fax:702-434-6424
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5287-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical