MEDICARE: MR. KELLY KENDRICKS

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
1	101YM0800X	Mental Health Counselor
2	101YP2500X	Professional Counselor	10694-125	WI

General Provider Information

NPI Number	:	1548872765
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KELLY KENDRICKS

Provider Business Mailing Address
First Line	:	206 S MARIETTA ST APT 101
Second Line	:
City	:	VERONA
State	:	WI
Zip	:	53593-1816
Country	:	US
Telephone Number	:	608-609-6761
Fax Number	:

Provider Business Practice Location Address
First Line	:	2002 ATWOOD AVE STE 225
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53704-5382
Country	:	US
Telephone Number	:	608-416-5245
Fax Number	:	608-416-5221

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2020
Last Update Date	:	11/21/2025

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