Basic Information
| Provider Information | |||||||||
| NPI: | 1558978825 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEBEDE | ||||||||
| FirstName: | EDEN | ||||||||
| MiddleName: | ADDISU | ||||||||
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| Credential: | LCSW-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 650 JOEL DRIVE | ||||||||
| Address2: | |||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707988400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | FT. CAMPBELL/BACH | ||||||||
| Address2: | 650 JOEL DRIVE | ||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707988400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2020 | ||||||||
| LastUpdateDate: | 09/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | P014936 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.