Provider Demographics
NPI:1275533796
Name:KEDROCK, BETTY ALEXANDRA (LCSW)
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:ALEXANDRA
Last Name:KEDROCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 COLLEY AVE
Mailing Address - Street 2:SUITE 312
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-1675
Mailing Address - Country:US
Mailing Address - Phone:757-640-0400
Mailing Address - Fax:757-640-0497
Practice Address - Street 1:1709 COLLEY AVE
Practice Address - Street 2:SUITE 312
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-1675
Practice Address - Country:US
Practice Address - Phone:757-640-0400
Practice Address - Fax:757-640-0497
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040002341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8908478Medicaid
A163599OtherVALUE OPTIONS
VA080436OtherOPTIMA
324004OtherMANAGED HEALTH NETWORK
247697OtherCOM PSYCH
VA049958OtherBLUE CROSS BLUE SHIELD
VA216188OtherUCH
VA5264256OtherAETNA
VA028883OtherVALUE OPTION
R65568Medicare UPIN