MEDICARE: TERESA WILIE KENNISON MS, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	5568	OK

General Provider Information

NPI Number	:	1083919179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESA WILIE KENNISON MS, LPC

Provider Business Mailing Address
First Line	:	113 W SHAWNEE ST
Second Line	:
City	:	TAHLEQUAH
State	:	OK
Zip	:	74464-3623
Country	:	US
Telephone Number	:	580-579-3620
Fax Number	:

Provider Business Practice Location Address
First Line	:	113 W SHAWNEE ST
Second Line	:
City	:	TAHLEQUAH
State	:	OK
Zip	:	74464-3623
Country	:	US
Telephone Number	:	580-579-3620
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2011
Last Update Date	:	01/11/2026

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