MEDICARE: KEVIN PATRICK FENNELL LSW, CCDC1

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	0028965	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518072404
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN PATRICK FENNELL LSW, CCDC1

Provider Business Mailing Address
First Line	:	732 BECKMAN ST
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45410-2165
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	732 BECKMAN ST
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45410-2165
Country	:	US
Telephone Number	:	937-253-1680
Fax Number	:

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

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	03/12/2025

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