Provider Demographics
NPI:1447591896
Name:KENISON, NATHAN GORDON (LMT)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:GORDON
Last Name:KENISON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 HERRICK ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-3125
Mailing Address - Country:US
Mailing Address - Phone:978-578-8323
Mailing Address - Fax:
Practice Address - Street 1:252 ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-2419
Practice Address - Country:US
Practice Address - Phone:978-578-8323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8979225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist