MEDICARE: PATRICIA 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
1	1041C0700X	Clinical Social Worker	12305	MT

General Provider Information

NPI Number	:	1679958706
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA KENNELLY LCSW

Provider Business Mailing Address
First Line	:	15 MONTANA AVE
Second Line	:
City	:	WHITEFISH
State	:	MT
Zip	:	59937-2224
Country	:	US
Telephone Number	:	713-586-9905
Fax Number	:

Provider Business Practice Location Address
First Line	:	309 WISCONSIN AVE
Second Line	:
City	:	WHITEFISH
State	:	MT
Zip	:	59937-2319
Country	:	US
Telephone Number	:	406-309-8450
Fax Number	:

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

Provider Enumeration Date	:	07/30/2015
Last Update Date	:	06/22/2016

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