Provider Demographics
NPI:1568402477
Name:KENNEDY, MORGAN REBECCA (PHD)
Entity Type:Individual
Prefix:
First Name:MORGAN
Middle Name:REBECCA
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 1:859 WASHINGTON ST # 203
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080-2704
Mailing Address - Country:US
Mailing Address - Phone:530-347-6000
Mailing Address - Fax:888-706-4141
Practice Address - Street 1:25 EVERGREEN AVE STE 3A
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-3399
Practice Address - Country:US
Practice Address - Phone:415-867-8524
Practice Address - Fax:888-706-4141
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19804103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
C1778ZMedicare PIN