Provider Demographics
NPI:1144602491
Name:KENYON, CARLY (MS, LCGC)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:KENYON
Suffix:
Gender:F
Credentials:MS, LCGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1559 PERSHING DR APT C
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94129-1232
Mailing Address - Country:US
Mailing Address - Phone:925-984-3279
Mailing Address - Fax:
Practice Address - Street 1:3700 CALIFORNIA ST RM 4360
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-1618
Practice Address - Country:US
Practice Address - Phone:415-600-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGC00596170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS