Provider Demographics
NPI:1760967400
Name:KIRKENDALL, SUSAN RENNAE (MS,AADC)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:RENNAE
Last Name:KIRKENDALL
Suffix:
Gender:F
Credentials:MS,AADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 ANDREW DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-6842
Mailing Address - Country:US
Mailing Address - Phone:304-290-6533
Mailing Address - Fax:
Practice Address - Street 1:527 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9008
Practice Address - Country:US
Practice Address - Phone:304-933-3884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-28
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV98-302101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)