Provider Demographics
NPI:1518072404
Name:FENNELL, KEVIN PATRICK (LSW, CCDC1)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:PATRICK
Last Name:FENNELL
Suffix:
Gender:M
Credentials:LSW, CCDC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 AUTUMN TREE PL
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-3114
Mailing Address - Country:US
Mailing Address - Phone:614-395-9262
Mailing Address - Fax:
Practice Address - Street 1:1791 ALUM CREEK DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-1708
Practice Address - Country:US
Practice Address - Phone:614-324-5414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH00289651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1518072404Medicaid
OH1518072404Medicaid