Provider Demographics
NPI:1710133301
Name:KENIN, SHERRY GAYLE (MS OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:SHERRY
Middle Name:GAYLE
Last Name:KENIN
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1269 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742
Mailing Address - Country:US
Mailing Address - Phone:978-728-7780
Mailing Address - Fax:978-287-7801
Practice Address - Street 1:1269 MAIN STREET
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742
Practice Address - Country:US
Practice Address - Phone:978-728-7780
Practice Address - Fax:978-287-7801
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-14
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111364225X00000X
DCOT010000310225X00000X
VA0119001432225X00000X
FLOT 13120225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000705700Medicaid