Provider Demographics
NPI:1558579151
Name:KENNEDY-BAXTER, LYNN A (LMFT)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:A
Last Name:KENNEDY-BAXTER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:2130 PROFESSIONAL DR STE 240
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3780
Mailing Address - Country:US
Mailing Address - Phone:719-534-3104
Mailing Address - Fax:
Practice Address - Street 1:2790 N ACADEMY BLVD
Practice Address - Street 2:SUITE 206
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5337
Practice Address - Country:US
Practice Address - Phone:719-534-3104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2019-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO939106H00000X
CA16946106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA77-0213449OtherTAX ID