MEDICARE: KENDRA KABONGO-FAROUL LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0904010439	VA

General Provider Information

NPI Number	:	1437639424
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENDRA KABONGO-FAROUL LCSW

Provider Business Mailing Address
First Line	:	3757 COCO PALM
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79936-2167
Country	:	US
Telephone Number	:	757-715-1263
Fax Number	:

Provider Business Practice Location Address
First Line	:	3757 COCO PALM
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79936-2167
Country	:	US
Telephone Number	:	757-715-1263
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2018
Last Update Date	:	08/19/2018

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