Individual
ILYSE KENNEDY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LPC
Contact information
Practice address
2113 RIDDLE RD, AUSTIN, TX 78748-1305
(512) 766-9702
Mailing address
6609 MANCHACA RD, AUSTIN, TX 78745-4934
(512) 766-9702
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
78789
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
84-3455289
EINS
TX
Enumeration date
11/04/2019
Last updated
11/05/2022
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