Healthcare Provider Details

I. General information

NPI: 1972689933
Provider Name (Legal Business Name): KENDRA KINNEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 WEST MAIN
CEDAREDGE CO
81413
US

IV. Provider business mailing address

295 NW 9TH ST
CEDAREDGE CO
81413-3527
US

V. Phone/Fax

Practice location:
  • Phone: 970-856-6970
  • Fax: 970-856-7752
Mailing address:
  • Phone: 970-856-6970
  • Fax: 970-856-7752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number991078
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier035353
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: