Healthcare Provider Details

I. General information

NPI: 1255143129
Provider Name (Legal Business Name): CASSANDRA MAE KENNISON AAP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

656 BEANVILLE RD
VERSHIRE VT
05079-4424
US

IV. Provider business mailing address

254 PLAINFIELD RD
WEST LEBANON NH
03784-2001
US

V. Phone/Fax

Practice location:
  • Phone: 802-498-5816
  • Fax:
Mailing address:
  • Phone: 603-298-2146
  • Fax: 603-298-2149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number149.0134026
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: