Provider Demographics
NPI:1588243570
Name:KENNEDY, ALLYSA MEGAN (RADT-I)
Entity type:Individual
Prefix:
First Name:ALLYSA
Middle Name:MEGAN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:RADT-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 TOWER WAY STE150A #4
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-4509
Mailing Address - Country:US
Mailing Address - Phone:661-634-9877
Mailing Address - Fax:
Practice Address - Street 1:1001 TOWER WAY STE 150A
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-1597
Practice Address - Country:US
Practice Address - Phone:661-634-9877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1376260120101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)