Provider Demographics
NPI:1699230250
Name:CHISAMORE, KENDRA JO (SLP)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:JO
Last Name:CHISAMORE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25325 COUNTY ROUTE 16
Mailing Address - Street 2:
Mailing Address - City:EVANS MILLS
Mailing Address - State:NY
Mailing Address - Zip Code:13637-3104
Mailing Address - Country:US
Mailing Address - Phone:315-286-1678
Mailing Address - Fax:
Practice Address - Street 1:21986 COLE RD
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619-9595
Practice Address - Country:US
Practice Address - Phone:315-493-5020
Practice Address - Fax:315-493-6031
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028479-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist