Healthcare Provider Details

I. General information

NPI: 1598976128
Provider Name (Legal Business Name): MICHAL MIRA KENNY MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 01/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 CHELMSFORD STREET
CHELMSFORD MA
01824-2307
US

IV. Provider business mailing address

201 CHELMSFORD STREET
CHELMSFORD MA
01824-2307
US

V. Phone/Fax

Practice location:
  • Phone: 978-256-1467
  • Fax: 978-256-7465
Mailing address:
  • Phone: 781-729-0633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4393
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: