Provider Demographics
NPI:1689754012
Name:HENRY, KENNETH GEORGE (PHD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:GEORGE
Last Name:HENRY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 DUAL HWY STE 303
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-6648
Mailing Address - Country:US
Mailing Address - Phone:301-739-0400
Mailing Address - Fax:301-739-0402
Practice Address - Street 1:163 THOMAS JOHNSON DR STE H
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4673
Practice Address - Country:US
Practice Address - Phone:301-694-9111
Practice Address - Fax:301-739-0402
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2201000526231H00000X
MD01467231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009451412Medicaid