Provider Demographics
NPI:1376149567
Name:HENDRICKS, KELLY ANN (LSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 N EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46201-3632
Mailing Address - Country:US
Mailing Address - Phone:317-372-3989
Mailing Address - Fax:
Practice Address - Street 1:436 5TH AVENUE
Practice Address - Street 2:
Practice Address - City:KOTZEBUE
Practice Address - State:AK
Practice Address - Zip Code:99752
Practice Address - Country:US
Practice Address - Phone:907-442-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33009759A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker