Healthcare Provider Details

I. General information

NPI: 1689305666
Provider Name (Legal Business Name): KENDELL GOODRUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2022
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 HAPPY VALLEY RD
GLASGOW KY
42141-1561
US

IV. Provider business mailing address

380 SUWANNEE TRAIL ST
BOWLING GREEN KY
42103-7956
US

V. Phone/Fax

Practice location:
  • Phone: 270-901-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number260362
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: