Basic Information
| Provider Information | |||||||||
| NPI: | 1104012483 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENNA | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | DIANE | ||||||||
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| Mailing Information | |||||||||
| Address1: | COMMUNITY RESEARCH FOUNDATION | ||||||||
| Address2: | 1202 MORENA BLVD., STE 100 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921103850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192750822 | ||||||||
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| Practice Location | |||||||||
| Address1: | 734 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921016502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192750822 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2007 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.