Healthcare Provider Details

I. General information

NPI: 1811545627
Provider Name (Legal Business Name): FENNEL EDWARD KPOLIE LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1239 PARKWAY AVE STE 102
EWING NJ
08628-3000
US

IV. Provider business mailing address

4512 KIRKWOOD HWY STE 300
WILMINGTON DE
19808-5129
US

V. Phone/Fax

Practice location:
  • Phone: 609-394-3010
  • Fax: 609-394-3010
Mailing address:
  • Phone: 302-623-7515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberQ1-0012005
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL05587600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: