Provider Demographics
NPI:1922691351
Name:KENYON, PETER MICHAEL (CDCA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:MICHAEL
Last Name:KENYON
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 GLESSNER AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-2141
Mailing Address - Country:US
Mailing Address - Phone:419-612-6372
Mailing Address - Fax:
Practice Address - Street 1:600 RUSSELL RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-1931
Practice Address - Country:US
Practice Address - Phone:419-612-6372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-17
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
OHCDCA.185626101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist