Provider Demographics
NPI:1669071577
Name:DE KENNEY, MARIA LUZ
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:LUZ
Last Name:DE KENNEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 ORR SQ
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-3216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 ORR SQ
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-3216
Practice Address - Country:US
Practice Address - Phone:857-261-7494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS60617728Medicaid