Healthcare Provider Details

I. General information

NPI: 1407415920
Provider Name (Legal Business Name): LAURETTA MARIE KENDIG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2019
Last Update Date: 11/27/2023
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4305 MACARTHUR AVE
DALLAS TX
75209-6511
US

IV. Provider business mailing address

4305 MACARTHUR AVE
DALLAS TX
75209-6511
US

V. Phone/Fax

Practice location:
  • Phone: 214-526-4525
  • Fax:
Mailing address:
  • Phone: 214-526-4525
  • Fax: 214-520-6468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number63344
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: