Provider Demographics
NPI:1104117308
Name:MCKENDRY, SUSAN (MA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MCKENDRY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 N FAYETTEVILLE ST
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27203-4595
Mailing Address - Country:US
Mailing Address - Phone:336-629-4471
Mailing Address - Fax:336-629-5805
Practice Address - Street 1:1205 N FAYETTEVILLE ST
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-4595
Practice Address - Country:US
Practice Address - Phone:336-629-4471
Practice Address - Fax:336-629-5805
Is Sole Proprietor?:No
Enumeration Date:2011-04-22
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC937101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6111817Medicaid