Basic Information
| Provider Information | |||||||||
| NPI: | 1407995475 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENNY | ||||||||
| FirstName: | CATHERINE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KENNY | ||||||||
| OtherFirstName: | CATHERINE | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1921 WALDEMERE ST | ||||||||
| Address2: | 701 | ||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342392943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414872160 | ||||||||
| FaxNumber: | 9414872168 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 BROTHER GEENEN WAY | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342367102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9415663220 | ||||||||
| FaxNumber: | 9419558214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 08/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | DR-24597 | CO | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 2004018921 | MO | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 207588906 | 05 | MO | MEDICAID |