Provider Demographics
NPI:1336596931
Name:PHOUMIVONG, KENDRA D (LMSW)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:D
Last Name:PHOUMIVONG
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:KENDRA
Other - Middle Name:
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5 SUMMER LAKE WAY
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31407-3534
Mailing Address - Country:US
Mailing Address - Phone:912-247-3969
Mailing Address - Fax:
Practice Address - Street 1:690 COURTENAY DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306-3421
Practice Address - Country:US
Practice Address - Phone:404-875-4551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR8033-M104100000X
AR8033-C1041C0700X
GACSW0068761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker