Provider Demographics
NPI:1912498908
Name:KENYON, ELLEN LEA (MS CCC-SLP/L)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:LEA
Last Name:KENYON
Suffix:
Gender:F
Credentials:MS CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1483 SW BOUGAINVILLEA AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-7302
Mailing Address - Country:US
Mailing Address - Phone:772-336-6928
Mailing Address - Fax:
Practice Address - Street 1:135 SNYDER RD
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-3431
Practice Address - Country:US
Practice Address - Phone:724-342-3898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL013942235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist