Provider Demographics
NPI:1558052100
Name:MARCUM, KENDRA RAE
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:RAE
Last Name:MARCUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 ROACH ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-9393
Mailing Address - Country:US
Mailing Address - Phone:502-863-4735
Mailing Address - Fax:502-863-4735
Practice Address - Street 1:110 ROACH ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9393
Practice Address - Country:US
Practice Address - Phone:502-863-4734
Practice Address - Fax:502-863-4735
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid