Provider Demographics
NPI:1467025387
Name:KENNEDY, COLLEEN MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:MARIE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14105 LOS NIETOS AVE
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-3020
Mailing Address - Country:US
Mailing Address - Phone:858-215-5131
Mailing Address - Fax:
Practice Address - Street 1:14105 LOS NIETOS AVE
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-3020
Practice Address - Country:US
Practice Address - Phone:858-215-5131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY32722103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical