MEDICARE: KENYETTA THURSTON

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	104100000X	Social Worker

General Provider Information

NPI Number	:	1043523194
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENYETTA THURSTON

Provider Business Mailing Address
First Line	:	25 KAHLER AVE
Second Line	:
City	:	MILTON
State	:	MA
Zip	:	02186-1537
Country	:	US
Telephone Number	:	617-680-3424
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 KAHLER AVE
Second Line	:
City	:	MILTON
State	:	MA
Zip	:	02186-1537
Country	:	US
Telephone Number	:	617-680-3424
Fax Number	:

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

Provider Enumeration Date	:	07/19/2010
Last Update Date	:	07/19/2010

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Directions to “ KENYETTA THURSTON ” Practice Location

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