Provider Demographics
NPI:1497498422
Name:MAHAN, KENDRA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:MAHAN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:KENDRA
Other - Middle Name:
Other - Last Name:PETTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:306 W BROAD ST STE B
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:38570-1804
Mailing Address - Country:US
Mailing Address - Phone:931-823-6136
Mailing Address - Fax:931-823-6138
Practice Address - Street 1:306 W BROAD ST STE B
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TN
Practice Address - Zip Code:38570-1804
Practice Address - Country:US
Practice Address - Phone:931-823-6136
Practice Address - Fax:931-823-6138
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6564235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist