Provider Demographics
NPI:1548872765
Name:KENDRICKS, KELLY
Entity type:Individual
Prefix:MR
First Name:KELLY
Middle Name:
Last Name:KENDRICKS
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 1:111 ACKER CT
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-2251
Mailing Address - Country:US
Mailing Address - Phone:608-609-6761
Mailing Address - Fax:
Practice Address - Street 1:2002 ATWOOD AVE STE 225
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-5382
Practice Address - Country:US
Practice Address - Phone:608-416-5245
Practice Address - Fax:608-416-5221
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4714-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health