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NPI Code Detail

MEDICARE: DANA MARIE KENNELLY LCSW

MEDICARE: DANA MARIE KENNELLY LCSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1104100000XSocial Worker3547ND
21041C0700XClinical Social Worker3547ND

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1027884OTHERNDBCBS PROVIDER NUMBER
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1457420754
Entity Type Code : Individual
Provider Name (Legal Business Name) : DANA MARIE KENNELLY LCSW
Provider Business Mailing Address
First Line : 2400 47TH AVE S
Second Line :
City : GRAND FORKS
State : ND
Zip : 58201-3405
Country : US
Telephone Number : 701-746-2200
Fax Number :
Provider Business Practice Location Address
First Line : 2400 47TH AVE S
Second Line :
City : GRAND FORKS
State : ND
Zip : 58201-3405
Country : US
Telephone Number : 701-215-5906
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/08/2006
Last Update Date : 09/09/2024

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