Provider Demographics
NPI:1366604498
Name:KLEIN-KENNEDY, DALE ROBIN (MA)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:ROBIN
Last Name:KLEIN-KENNEDY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:DALE
Other - Middle Name:ROBIN
Other - Last Name:KLEIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:10709 CIELO VISTA DEL NORTE
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-8905
Mailing Address - Country:US
Mailing Address - Phone:505-350-4237
Mailing Address - Fax:505-843-9520
Practice Address - Street 1:10709 CIELO VISTA DEL NORTE
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-8905
Practice Address - Country:US
Practice Address - Phone:505-350-4237
Practice Address - Fax:505-843-9520
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0074381101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health