Provider Demographics
NPI:1760597330
Name:KENNAN, BONNIE RAY (PSYD MFT)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:RAY
Last Name:KENNAN
Suffix:
Gender:F
Credentials:PSYD MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25550 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505
Mailing Address - Country:US
Mailing Address - Phone:310-265-6644
Mailing Address - Fax:310-377-2941
Practice Address - Street 1:25550 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 212
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505
Practice Address - Country:US
Practice Address - Phone:310-265-6644
Practice Address - Fax:310-377-2941
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC38442103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist