Provider Demographics
NPI:1497253488
Name:KENNIS, MELISSA (MS)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:KENNIS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 BIRCH DR
Mailing Address - Street 2:
Mailing Address - City:ANITA
Mailing Address - State:PA
Mailing Address - Zip Code:15711-9720
Mailing Address - Country:US
Mailing Address - Phone:814-952-5766
Mailing Address - Fax:
Practice Address - Street 1:117 ELK RUN AVE
Practice Address - Street 2:
Practice Address - City:PUNXSUTAWNEY
Practice Address - State:PA
Practice Address - Zip Code:15767-1617
Practice Address - Country:US
Practice Address - Phone:814-938-6340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101Y00000X
PAPC015558101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor