Provider Demographics
NPI:1285403105
Name:KENNERLY, MARY HELEN (LMFT)
Entity type:Individual
Prefix:
First Name:MARY HELEN
Middle Name:
Last Name:KENNERLY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 NORTHGATE DR STE E
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52245-9501
Mailing Address - Country:US
Mailing Address - Phone:413-237-5208
Mailing Address - Fax:
Practice Address - Street 1:3030 NORTHGATE DR STE E
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52245-9501
Practice Address - Country:US
Practice Address - Phone:413-237-5208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA107684106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist