Provider Demographics
NPI:1700117512
Name:KENDRICK, ROSALIND MARIE (MED)
Entity Type:Individual
Prefix:
First Name:ROSALIND
Middle Name:MARIE
Last Name:KENDRICK
Suffix:
Gender:F
Credentials:MED
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 28414
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87592-8414
Mailing Address - Country:US
Mailing Address - Phone:918-658-8452
Mailing Address - Fax:
Practice Address - Street 1:22662 HILLTOP RD
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-9058
Practice Address - Country:US
Practice Address - Phone:918-658-8452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-18
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1700117512Medicaid