Provider Demographics
NPI:1376851337
Name:KENNARD, MARK S (LICSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:KENNARD
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 390
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01903-0490
Mailing Address - Country:US
Mailing Address - Phone:781-593-5333
Mailing Address - Fax:781-581-2177
Practice Address - Street 1:280 UNION ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1353
Practice Address - Country:US
Practice Address - Phone:781-581-9270
Practice Address - Fax:781-581-8413
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA105281101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)