Provider Demographics
NPI:1184187353
Name:O'BERRY, KENDRA ELISE (LISW)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:ELISE
Last Name:O'BERRY
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:534 DOVE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841-2982
Mailing Address - Country:US
Mailing Address - Phone:404-759-5467
Mailing Address - Fax:
Practice Address - Street 1:534 DOVE ST
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841-2982
Practice Address - Country:US
Practice Address - Phone:404-759-5467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-12
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
GACSW0071821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC12108OtherSC LICENSURE