Provider Demographics
NPI:1922436138
Name:KENYON, KRISTIE LYNN (LICSW)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:LYNN
Last Name:KENYON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 W FOSTER ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-3879
Mailing Address - Country:US
Mailing Address - Phone:617-610-9415
Mailing Address - Fax:
Practice Address - Street 1:1 W FOSTER ST
Practice Address - Street 2:SUITE 5
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-3879
Practice Address - Country:US
Practice Address - Phone:617-610-9415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-25
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1171511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical