Provider Demographics
NPI:1881822658
Name:KENNEDY, KRISTINE LOUANN (BA, CADC)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:LOUANN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:BA, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:CHARITON
Mailing Address - State:IA
Mailing Address - Zip Code:50049-1210
Mailing Address - Country:US
Mailing Address - Phone:641-774-3370
Mailing Address - Fax:641-774-3261
Practice Address - Street 1:1200 N 7TH ST
Practice Address - Street 2:
Practice Address - City:CHARITON
Practice Address - State:IA
Practice Address - Zip Code:50049-1210
Practice Address - Country:US
Practice Address - Phone:641-774-3370
Practice Address - Fax:641-774-3261
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA09054101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)