Provider Demographics
NPI:1003582305
Name:SOUZA, KENNIDY RAE
Entity type:Individual
Prefix:
First Name:KENNIDY
Middle Name:RAE
Last Name:SOUZA
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 1:4947 ARCHDALE LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-2317
Mailing Address - Country:US
Mailing Address - Phone:614-822-9052
Mailing Address - Fax:
Practice Address - Street 1:3493 BIGBY HOLLOW CT
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-9787
Practice Address - Country:US
Practice Address - Phone:614-405-0463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.2404582101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health