Provider Demographics
NPI:1164165056
Name:KENNERLY, TAYLOR CHARISSE (LGPC)
Entity Type:Individual
Prefix:MS
First Name:TAYLOR
Middle Name:CHARISSE
Last Name:KENNERLY
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4351 TELFAIR BLVD APT G101
Mailing Address - Street 2:
Mailing Address - City:CAMP SPRINGS
Mailing Address - State:MD
Mailing Address - Zip Code:20746-4285
Mailing Address - Country:US
Mailing Address - Phone:203-216-4252
Mailing Address - Fax:
Practice Address - Street 1:3261 OLD WASHINGTON RD STE 3021
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3229
Practice Address - Country:US
Practice Address - Phone:240-280-3245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP11841101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health