Provider Demographics
NPI:1699182220
Name:KENYON, KRYSTLE LEE (MSED)
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:LEE
Last Name:KENYON
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 ABBOTT AVE
Mailing Address - Street 2:
Mailing Address - City:MASTIC
Mailing Address - State:NY
Mailing Address - Zip Code:11950
Mailing Address - Country:US
Mailing Address - Phone:631-926-9358
Mailing Address - Fax:
Practice Address - Street 1:38 ABBOTT AVE
Practice Address - Street 2:
Practice Address - City:MASTIC
Practice Address - State:NY
Practice Address - Zip Code:11950-1533
Practice Address - Country:US
Practice Address - Phone:631-926-9358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool