MEDICARE: MEGAN KENNEDY- KOTALIK 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	104100000X	Social Worker	60759	TX

General Provider Information

NPI Number	:	1528456985
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MEGAN KENNEDY- KOTALIK LCSW

Provider Business Mailing Address
First Line	:	816 EDGEFIELD DR
Second Line	:
City	:	RICHARDSON
State	:	TX
Zip	:	75080-4032
Country	:	US
Telephone Number	:	214-729-9194
Fax Number	:

Provider Business Practice Location Address
First Line	:	509 N WINNETKA AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75208-5141
Country	:	US
Telephone Number	:	972-755-9120
Fax Number	:

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

Provider Enumeration Date	:	01/07/2015
Last Update Date	:	02/26/2019

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