Provider Demographics
NPI:1053798074
Name:KENNY, CAROL (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:KENNY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:792 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-1627
Mailing Address - Country:US
Mailing Address - Phone:618-833-5001
Mailing Address - Fax:618-833-5001
Practice Address - Street 1:792 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-1627
Practice Address - Country:US
Practice Address - Phone:618-833-5001
Practice Address - Fax:618-833-5001
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-28
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.006539235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist