Provider Demographics
NPI:1568021061
Name:KENNEDY, KATRINA L
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:L
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 SW BARNES RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6258
Mailing Address - Country:US
Mailing Address - Phone:503-278-2050
Mailing Address - Fax:
Practice Address - Street 1:422 NW 13TH AVE STE 115
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2930
Practice Address - Country:US
Practice Address - Phone:888-657-4456
Practice Address - Fax:415-989-5001
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician