Provider Demographics
NPI:1811545627
Name:KPOLIE, FENNEL EDWARD (LSW)
Entity Type:Individual
Prefix:MR
First Name:FENNEL
Middle Name:EDWARD
Last Name:KPOLIE
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4512 KIRKWOOD HWY
Mailing Address - Street 2:STE 300
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-5129
Mailing Address - Country:US
Mailing Address - Phone:302-623-7515
Mailing Address - Fax:
Practice Address - Street 1:1239 PARKWAY AVE STE 102
Practice Address - Street 2:
Practice Address - City:EWING
Practice Address - State:NJ
Practice Address - Zip Code:08628-3000
Practice Address - Country:US
Practice Address - Phone:609-394-3010
Practice Address - Fax:609-394-3010
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ1-00120051041C0700X
NJ44SL05587600104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty