Basic Information
| Provider Information | |||||||||
| NPI: | 1003582305 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOUZA | ||||||||
| FirstName: | KENNIDY | ||||||||
| MiddleName: | RAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6374 NEWTOWN DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432317602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033629598 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5548 HILLIARD ROME OFFICE PARK | ||||||||
| Address2: | |||||||||
| City: | HILLIARD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430267286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7408458652 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2021 | ||||||||
| LastUpdateDate: | 08/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | C.2103297-TRNE | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.