Provider Demographics
NPI:1396137667
Name:KENDRICK, MENNARD (LMSW, MPA, CAADC)
Entity type:Individual
Prefix:
First Name:MENNARD
Middle Name:
Last Name:KENDRICK
Suffix:
Gender:M
Credentials:LMSW, MPA, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776982
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6982
Mailing Address - Country:US
Mailing Address - Phone:231-672-2119
Mailing Address - Fax:
Practice Address - Street 1:125 E SOUTHERN AVE STE 100
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5041
Practice Address - Country:US
Practice Address - Phone:231-672-3582
Practice Address - Fax:231-722-6933
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011174341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1396137667Medicaid