Provider Demographics
NPI:1932349677
Name:KWOCZALLA, KENDRICK (LMHC)
Entity Type:Individual
Prefix:
First Name:KENDRICK
Middle Name:
Last Name:KWOCZALLA
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S WASHINGTON ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-3867
Mailing Address - Country:US
Mailing Address - Phone:765-662-9971
Mailing Address - Fax:765-651-6563
Practice Address - Street 1:101 S WASHINGTON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-3867
Practice Address - Country:US
Practice Address - Phone:765-662-9971
Practice Address - Fax:765-651-6563
Is Sole Proprietor?:No
Enumeration Date:2009-02-20
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002202A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100124250Medicaid