Provider Demographics
NPI:1275869653
Name:KENISON, CAROL ANN (MA, LLP, LPC)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:ANN
Last Name:KENISON
Suffix:
Gender:F
Credentials:MA, LLP, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 S WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-2950
Mailing Address - Country:US
Mailing Address - Phone:248-867-2499
Mailing Address - Fax:
Practice Address - Street 1:130 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MI
Practice Address - Zip Code:49651-5103
Practice Address - Country:US
Practice Address - Phone:231-295-1196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-20
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008847101YP2500X, 101Y00000X
MI6301013036103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical