Provider Demographics
NPI:1508324690
Name:LONG, KENDRA HALL
Entity Type:Individual
Prefix:MRS
First Name:KENDRA
Middle Name:HALL
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KENDRA
Other - Middle Name:LEE
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4093 WOODLAWN RD
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-9205
Mailing Address - Country:US
Mailing Address - Phone:502-510-2912
Mailing Address - Fax:
Practice Address - Street 1:4093 WOODLAWN RD
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-9205
Practice Address - Country:US
Practice Address - Phone:502-510-2912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist