Provider Demographics
NPI:1194039891
Name:KENISON, MARCY L
Entity Type:Individual
Prefix:
First Name:MARCY
Middle Name:L
Last Name:KENISON
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 1:35 LAKE AUBURN AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210-6003
Mailing Address - Country:US
Mailing Address - Phone:207-784-5467
Mailing Address - Fax:
Practice Address - Street 1:35 LAKE AUBURN AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-6003
Practice Address - Country:US
Practice Address - Phone:207-784-5467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP778235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist