Provider Demographics
NPI:1376017988
Name:RICHARDSON, KENDRA BERNITTA
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:BERNITTA
Last Name:RICHARDSON
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 1:57 LEE ROAD 2212
Mailing Address - Street 2:
Mailing Address - City:SMITHS STATION
Mailing Address - State:AL
Mailing Address - Zip Code:36877-3392
Mailing Address - Country:US
Mailing Address - Phone:256-653-6340
Mailing Address - Fax:
Practice Address - Street 1:6600 VAN AALST BLVD
Practice Address - Street 2:
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-2102
Practice Address - Country:US
Practice Address - Phone:706-544-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4222G104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker