Provider Demographics
NPI:1255143129
Name:KENNISON, CASSANDRA MAE (AAP)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:MAE
Last Name:KENNISON
Suffix:
Gender:F
Credentials:AAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 PLAINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WEST LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03784-2001
Mailing Address - Country:US
Mailing Address - Phone:603-298-2146
Mailing Address - Fax:603-298-2149
Practice Address - Street 1:656 BEANVILLE RD
Practice Address - Street 2:
Practice Address - City:VERSHIRE
Practice Address - State:VT
Practice Address - Zip Code:05079-4424
Practice Address - Country:US
Practice Address - Phone:802-498-5816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT149.0134026101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)