Provider Demographics
NPI:1790052181
Name:KENNEDY, KRISTIN (LADAC)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6464 MONTE SERRANO NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-1284
Mailing Address - Country:US
Mailing Address - Phone:505-715-2577
Mailing Address - Fax:
Practice Address - Street 1:6464 MONTE SERRANO NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-1284
Practice Address - Country:US
Practice Address - Phone:505-715-2577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0089291101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)