Provider Demographics
NPI:1164721155
Name:SHOUP, KENDRA ANN
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:ANN
Last Name:SHOUP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18645 DETROIT AVE
Mailing Address - Street 2:APT 621
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-3276
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:347 MIDWAY BLVD
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-9006
Practice Address - Country:US
Practice Address - Phone:440-324-5701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.0900277-CR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health