Provider Demographics
NPI:1467750547
Name:DYER, KENDRICK G (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KENDRICK
Middle Name:G
Last Name:DYER
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 1:3278 MITCHELL BLVD
Mailing Address - Street 2:
Mailing Address - City:MOODY AFB
Mailing Address - State:GA
Mailing Address - Zip Code:31699-1500
Mailing Address - Country:US
Mailing Address - Phone:229-257-4805
Mailing Address - Fax:229-257-4409
Practice Address - Street 1:3278 MITCHELL BLVD
Practice Address - Street 2:
Practice Address - City:MOODY AFB
Practice Address - State:GA
Practice Address - Zip Code:31699-1500
Practice Address - Country:US
Practice Address - Phone:229-257-4805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-14
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0043231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA004323OtherLICENSE