Provider Demographics
NPI:1538955984
Name:MCINTYRE, KENNETH MICHAEL (LDAC II)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:MICHAEL
Last Name:MCINTYRE
Suffix:
Gender:
Credentials:LDAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 LORING AVE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-4350
Mailing Address - Country:US
Mailing Address - Phone:617-694-5593
Mailing Address - Fax:
Practice Address - Street 1:66 CANAL ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2002
Practice Address - Country:US
Practice Address - Phone:617-694-5593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-15
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16841101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)