MEDICARE: DEREK KENNIE

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1992641955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK KENNIE

Provider Business Mailing Address
First Line	:	2250 PENDRELL LN
Second Line	:
City	:	CORDOVA
State	:	TN
Zip	:	38016-5398
Country	:	US
Telephone Number	:	901-277-1107
Fax Number	:

Provider Business Practice Location Address
First Line	:	2250 PENDRELL LN
Second Line	:
City	:	CORDOVA
State	:	TN
Zip	:	38016-5398
Country	:	US
Telephone Number	:	901-277-1107
Fax Number	:

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

Provider Enumeration Date	:	04/23/2026
Last Update Date	:	04/23/2026

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Directions to “ DEREK KENNIE ” Practice Location

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