Provider Demographics
NPI:1760927412
Name:KENNEDY-ROSS, MIMI M (LPC)
Entity Type:Individual
Prefix:
First Name:MIMI
Middle Name:M
Last Name:KENNEDY-ROSS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DODGE & MT LEMMON RD
Mailing Address - Street 2:
Mailing Address - City:ORACLE
Mailing Address - State:AZ
Mailing Address - Zip Code:85623
Mailing Address - Country:US
Mailing Address - Phone:520-896-9240
Mailing Address - Fax:
Practice Address - Street 1:DODGE & MT LEMMON RD
Practice Address - Street 2:
Practice Address - City:ORACLE
Practice Address - State:AZ
Practice Address - Zip Code:85623
Practice Address - Country:US
Practice Address - Phone:520-896-9240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-16413101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional