Provider Demographics
NPI:1407892656
Name:KENT, DAVID WILLIS (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:WILLIS
Last Name:KENT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 S FLORAL AVE
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33830
Mailing Address - Country:US
Mailing Address - Phone:863-534-8211
Mailing Address - Fax:863-534-8211
Practice Address - Street 1:930 ALICEA RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33810
Practice Address - Country:US
Practice Address - Phone:863-680-1950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCAP3269101YA0400X
FLSW50541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL762848000Medicaid
FL762848000Medicaid