Provider Demographics
NPI:1699364406
Name:KENNARD, BERNADETTE MARLENE
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:MARLENE
Last Name:KENNARD
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:PO BOX 17988
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-7988
Mailing Address - Country:US
Mailing Address - Phone:562-999-1292
Mailing Address - Fax:
Practice Address - Street 1:1529 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-6129
Practice Address - Country:US
Practice Address - Phone:562-999-1292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9152235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist