Healthcare Provider Details

I. General information

NPI: 1992613855
Provider Name (Legal Business Name): KENDRA MICKENS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CITY AVE STE 104
BALA CYNWYD PA
19004-1724
US

IV. Provider business mailing address

5901 NASSAU RD STE 1
PHILADELPHIA PA
19151-3540
US

V. Phone/Fax

Practice location:
  • Phone: 717-268-9479
  • Fax:
Mailing address:
  • Phone: 267-314-9477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW143260
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: