Provider Demographics
NPI:1689091258
Name:KENNARD, JUSTIN DAVID (LCSW)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DAVID
Last Name:KENNARD
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 1:4751 COMMONWEALTH ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48208-2225
Mailing Address - Country:US
Mailing Address - Phone:973-214-9110
Mailing Address - Fax:
Practice Address - Street 1:111 E KIRBY ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-4003
Practice Address - Country:US
Practice Address - Phone:347-690-0774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-21
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011005401041C0700X
NY0790361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical