Provider Demographics
NPI:1649282054
Name:KENNY, GINA M (PHD)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:M
Last Name:KENNY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:M
Other - Last Name:PORRETTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:216 VAUGHAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3204
Mailing Address - Country:US
Mailing Address - Phone:207-662-2221
Mailing Address - Fax:207-662-6327
Practice Address - Street 1:216 VAUGHAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3204
Practice Address - Country:US
Practice Address - Phone:207-662-2221
Practice Address - Fax:207-662-6327
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS975103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEUX5464Medicare PIN