Healthcare Provider Details

I. General information

NPI: 1497166631
Provider Name (Legal Business Name): NICHOLAS KENDUS M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2014
Last Update Date: 05/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 WATERLOO BLVD SUITE 120
EXTON PA
19341-2603
US

IV. Provider business mailing address

410 N PRINCE ST
LANCASTER PA
17603-3010
US

V. Phone/Fax

Practice location:
  • Phone: 610-363-5500
  • Fax:
Mailing address:
  • Phone: 717-560-7917
  • Fax: 717-208-7105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC007533
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1053341859
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: