Provider Demographics
NPI:1598320392
Name:KENNEDY, ERIKA (MED, LPC)
Entity Type:Individual
Prefix:
First Name:ERIKA
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4142 KEATON CROSSING BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8406
Mailing Address - Country:US
Mailing Address - Phone:636-300-9333
Mailing Address - Fax:
Practice Address - Street 1:4142 KEATON CROSSING BLVD STE 101
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-8406
Practice Address - Country:US
Practice Address - Phone:636-300-9333
Practice Address - Fax:636-300-8761
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-07
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019007334101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional