Healthcare Provider Details

I. General information

NPI: 1023772779
Provider Name (Legal Business Name): KELLY E FENWICK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2021
Last Update Date: 10/11/2024
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 LINCOLN PARK RD
SPRINGFIELD KY
40069-1501
US

IV. Provider business mailing address

PO BOX 1080
BURKESVILLE KY
42717-1080
US

V. Phone/Fax

Practice location:
  • Phone: 844-435-0900
  • Fax: 270-858-4029
Mailing address:
  • Phone: 270-858-6655
  • Fax: 270-858-4027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number256116
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: