Provider Demographics
NPI:1427655026
Name:KENNEDY, ALYSSA (MHCAMC61326327)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MHCAMC61326327
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED, MHCA
Mailing Address - Street 1:3208 FALK RD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-5607
Mailing Address - Country:US
Mailing Address - Phone:360-394-4483
Mailing Address - Fax:
Practice Address - Street 1:601 MAIN ST STE 206
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-3403
Practice Address - Country:US
Practice Address - Phone:360-839-4483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMHCA.MC.61326327101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor