1104973494 NPI number — MS. REGINA KENNEDY LMFT

Table of content: MS. REGINA KENNEDY LMFT (NPI 1104973494)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104973494 NPI number — MS. REGINA KENNEDY LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENNEDY
Provider First Name:
REGINA
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104973494
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3081
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92519-3081
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-539-7007
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4000 ORANGE ST
Provider Second Line Business Practice Location Address:
FORENSIC MENTAL HEALTH
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92501-3613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-955-4545
Provider Business Practice Location Address Fax Number:
951-955-2138
Provider Enumeration Date:
01/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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