Healthcare Provider Details

I. General information

NPI: 1689754012
Provider Name (Legal Business Name): KENNETH GEORGE HENRY PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 01/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 THOMAS JOHNSON DR STE H
FREDERICK MD
21702-4673
US

IV. Provider business mailing address

1800 DUAL HWY STE 303
HAGERSTOWN MD
21740-6648
US

V. Phone/Fax

Practice location:
  • Phone: 301-694-9111
  • Fax: 301-739-0402
Mailing address:
  • Phone: 301-739-0400
  • Fax: 301-739-0402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number2201000526
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number01467
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: