Provider Demographics
NPI:1336634955
Name:FRY, KENDRA KAY
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:KAY
Last Name:FRY
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 1:107 SHILOH DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-7301
Mailing Address - Country:US
Mailing Address - Phone:618-242-6944
Mailing Address - Fax:
Practice Address - Street 1:107 SHILOH DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-7301
Practice Address - Country:US
Practice Address - Phone:618-242-6944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health