Provider Demographics
NPI:1215617865
Name:MACON, KERRI
Entity type:Individual
Prefix:
First Name:KERRI
Middle Name:
Last Name:MACON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 WOODBINE RD
Mailing Address - Street 2:
Mailing Address - City:SHELBURNE
Mailing Address - State:VT
Mailing Address - Zip Code:05482-6702
Mailing Address - Country:US
Mailing Address - Phone:802-578-9278
Mailing Address - Fax:
Practice Address - Street 1:45 WOODBINE RD
Practice Address - Street 2:
Practice Address - City:SHELBURNE
Practice Address - State:VT
Practice Address - Zip Code:05482-6702
Practice Address - Country:US
Practice Address - Phone:802-578-9278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty