Provider Demographics
NPI:1518323138
Name:RETALIC, KENDRA
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:RETALIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BRANCH ST
Mailing Address - Street 2:STE 202
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-1923
Mailing Address - Country:US
Mailing Address - Phone:781-219-7654
Mailing Address - Fax:
Practice Address - Street 1:1 BRANCH ST
Practice Address - Street 2:STE 202
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844-1923
Practice Address - Country:US
Practice Address - Phone:781-219-7654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9321225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist