Provider Demographics
NPI:1699945667
Name:FENLON, KEVIN JOSEPH
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOSEPH
Last Name:FENLON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 SPRUCEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-1193
Mailing Address - Country:US
Mailing Address - Phone:508-852-1851
Mailing Address - Fax:
Practice Address - Street 1:57 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01581-1464
Practice Address - Country:US
Practice Address - Phone:508-366-0406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6441101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health