Basic Information
| Provider Information | |||||||||
| NPI: | 1376149567 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDRICKS | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 126 N EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462013632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173723989 | ||||||||
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| Practice Location | |||||||||
| Address1: | 436 5TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | KOTZEBUE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074423321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2020 | ||||||||
| LastUpdateDate: | 12/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 33009759A | IN | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.