Provider Demographics
NPI:1780896209
Name:LENNON, KRISTEN TRACY (MFT)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:TRACY
Last Name:LENNON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14425 ROCK PLACE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-7255
Mailing Address - Country:US
Mailing Address - Phone:951-205-9708
Mailing Address - Fax:951-789-7683
Practice Address - Street 1:3590 CENTRAL AVENUE
Practice Address - Street 2:SUITE # 208
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506
Practice Address - Country:US
Practice Address - Phone:951-320-1390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39481106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist