Provider Demographics
NPI:1265694103
Name:KENNEBECK, DANIELLE DENISE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:DENISE
Last Name:KENNEBECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:DENISE
Other - Last Name:KENNEBECK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1800 SYRACUSE AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-2458
Mailing Address - Country:US
Mailing Address - Phone:402-371-8834
Mailing Address - Fax:402-379-0988
Practice Address - Street 1:1800 SYRACUSE AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-2458
Practice Address - Country:US
Practice Address - Phone:402-371-8834
Practice Address - Fax:402-379-0988
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
STUDENT101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)