Healthcare Provider Details

I. General information

NPI: 1225467152
Provider Name (Legal Business Name): CRYSTAL KENNEY LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2013
Last Update Date: 11/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 HOPE ST
MT. WASHINGTON KY
40047
US

IV. Provider business mailing address

PO BOX 1579
MT WASHINGTON KY
40047-1579
US

V. Phone/Fax

Practice location:
  • Phone: 502-538-1200
  • Fax: 502-538-1201
Mailing address:
  • Phone: 502-538-1200
  • Fax: 502-538-1201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number3733
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: