Provider Demographics
NPI:1710004197
Name:KERSHENBAUM, EILEEN
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:KERSHENBAUM
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 1:8515 ENSLEY PL
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66206-1456
Mailing Address - Country:US
Mailing Address - Phone:913-649-5377
Mailing Address - Fax:
Practice Address - Street 1:10015 N AMBASSADOR DR
Practice Address - Street 2:SUITE 101
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64153-1437
Practice Address - Country:US
Practice Address - Phone:816-891-7162
Practice Address - Fax:816-891-6704
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO001247225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2001247OtherLICENSE#