Provider Demographics
NPI:1568942415
Name:KENNEDY, NICOLE ROSE (LMHCA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ROSE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E 8TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-3294
Mailing Address - Country:US
Mailing Address - Phone:971-363-5757
Mailing Address - Fax:
Practice Address - Street 1:101 E 8TH ST STE 110
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-3294
Practice Address - Country:US
Practice Address - Phone:971-363-5757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60953974101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health