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NPI Code Detail

MEDICARE: KENNEDY M BROCK LSW

MEDICARE: KENNEDY M BROCK LSW
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
1101YA0400XAddiction (Substance Use Disorder) CounselorCDCA.169575OH
2171M00000XCase Manager/Care Coordinator
3104100000XSocial WorkerS.2512279OH

General Provider Information

NPI Number : 1811556244
Entity Type Code : Individual
Provider Name (Legal Business Name) : KENNEDY M BROCK LSW
Provider Business Mailing Address
First Line : 113 W GAMBIER ST
Second Line :
City : MOUNT VERNON
State : OH
Zip : 43050-2421
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 113 W GAMBIER ST
Second Line :
City : MOUNT VERNON
State : OH
Zip : 43050-2421
Country : US
Telephone Number : 740-326-9099
Fax Number : 740-326-9099
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/10/2019
Last Update Date : 08/01/2025

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