Provider Demographics
NPI:1306370242
Name:TENNILL, KEVIN (PLPC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:TENNILL
Suffix:
Gender:M
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 PERUQUE CROSSING CT
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-2362
Mailing Address - Country:US
Mailing Address - Phone:636-887-3655
Mailing Address - Fax:
Practice Address - Street 1:2828 E HIGHWAY 47
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:MO
Practice Address - Zip Code:63389-3027
Practice Address - Country:US
Practice Address - Phone:636-328-8248
Practice Address - Fax:636-668-6125
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016045020101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional