Provider Demographics
NPI:1275869653
Name:KENISON, CAROL ANN (MA, LLP, LPC)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:ANN
Last Name:KENISON
Suffix:
Gender:F
Credentials:MA, LLP, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 S WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-2950
Mailing Address - Country:US
Mailing Address - Phone:248-867-2499
Mailing Address - Fax:
Practice Address - Street 1:18316 MIDDLEBELT RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-5007
Practice Address - Country:US
Practice Address - Phone:248-615-9730
Practice Address - Fax:248-615-1260
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008847101YP2500X
MI6301013036103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical