=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962283770
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENDRA MINA LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2023
-----------------------------------------------------
Last Update Date | 10/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3309 CUMMINGS HWY STE 110
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37419-2438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-521-2735
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5555 HIXSON PIKE APT 207
-----------------------------------------------------
City | HIXSON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37343-3202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-521-2735
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 9132
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 9132
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------