Provider Demographics
NPI:1619669892
Name:KENNEDY, MONIQUE IRESHA
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:IRESHA
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 1:7912 CROYDON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3031
Mailing Address - Country:US
Mailing Address - Phone:310-497-7044
Mailing Address - Fax:
Practice Address - Street 1:16250 VENTURA BLVD STE 465
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-4620
Practice Address - Country:US
Practice Address - Phone:818-906-0406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA116810106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist