Provider Demographics
NPI:1285043588
Name:LENDERMAN, KELLY NICHOLE (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:NICHOLE
Last Name:LENDERMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:LENDERMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:1815 PLEASANT GROVE ROAD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-7870
Mailing Address - Country:US
Mailing Address - Phone:870-933-6886
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:1101 MORGAN STREET
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-3949
Practice Address - Country:US
Practice Address - Phone:870-335-9483
Practice Address - Fax:870-335-9483
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR8367-M104100000X
AR8367-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker