Provider Demographics
NPI:1467902049
Name:KENNINGTON, MARY GILL (SSP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:GILL
Last Name:KENNINGTON
Suffix:
Gender:F
Credentials:SSP
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 770
Mailing Address - Street 2:1475 E. LIBERTY STREET
Mailing Address - City:YORK
Mailing Address - State:SC
Mailing Address - Zip Code:29745-0770
Mailing Address - Country:US
Mailing Address - Phone:803-684-9916
Mailing Address - Fax:803-684-1903
Practice Address - Street 1:18 SPRUCE STREET
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:SC
Practice Address - Zip Code:29745-0770
Practice Address - Country:US
Practice Address - Phone:803-684-1905
Practice Address - Fax:803-684-1907
Is Sole Proprietor?:No
Enumeration Date:2016-10-07
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC160509103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool