Provider Demographics
NPI:1720807324
Name:KENNEDY, SANDRA
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:
Last Name:KENNEDY
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 1:5154 SNYDER LN
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-2943
Mailing Address - Country:US
Mailing Address - Phone:707-588-5600
Mailing Address - Fax:
Practice Address - Street 1:5154 SNYDER LN
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2943
Practice Address - Country:US
Practice Address - Phone:707-588-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11572101YP2500X
CA133631101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional