Provider Demographics
NPI:1043800584
Name:DEGRUY, KENDRAH
Entity Type:Individual
Prefix:
First Name:KENDRAH
Middle Name:
Last Name:DEGRUY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:276 BOULDER RUN
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-4257
Mailing Address - Country:US
Mailing Address - Phone:404-618-2086
Mailing Address - Fax:
Practice Address - Street 1:276 BOULDER RUN
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-4257
Practice Address - Country:US
Practice Address - Phone:404-618-2086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008673101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional