Provider Demographics
NPI:1275750226
Name:HENDRICKSON, KEVIN DOUGLAS (LCSW, BCETS)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:DOUGLAS
Last Name:HENDRICKSON
Suffix:
Gender:M
Credentials:LCSW, BCETS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 MOONSEED TRL
Mailing Address - Street 2:
Mailing Address - City:BOSTIC
Mailing Address - State:NC
Mailing Address - Zip Code:28018-9702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 FAIRGROUND RD
Practice Address - Street 2:
Practice Address - City:SPINDALE
Practice Address - State:NC
Practice Address - Zip Code:28160
Practice Address - Country:US
Practice Address - Phone:828-288-2757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0048271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical