Provider Demographics
NPI:1881774149
Name:KENAN, MARY M (PSYD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:KENAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:M
Other - Last Name:KENAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:7200 CAMBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-4202
Mailing Address - Country:US
Mailing Address - Phone:713-798-2273
Mailing Address - Fax:
Practice Address - Street 1:2500 E T C JESTER BLVD STE 238
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-1449
Practice Address - Country:US
Practice Address - Phone:713-826-1587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30875103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX040983101Medicaid
TX040983101Medicaid
82850PMedicare PIN