Provider Demographics
NPI:1164543401
Name:CAIN, KENDALL (SLP)
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:
Last Name:CAIN
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 541415
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-1415
Mailing Address - Country:US
Mailing Address - Phone:214-213-0054
Mailing Address - Fax:
Practice Address - Street 1:620 W WESTCHESTER PKWY
Practice Address - Street 2:5204
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-3299
Practice Address - Country:US
Practice Address - Phone:214-213-0054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101594235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX180149001Medicaid
TX180149003Medicaid
TX1376590422Medicaid