Basic Information
| Provider Information | |||||||||
| NPI: | 1023772779 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FENWICK | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | CSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 107 CRANES ROOST CT | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427013650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707652605 | ||||||||
| FaxNumber: | 8593367746 | ||||||||
| Practice Location | |||||||||
| Address1: | 324 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400691127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593367746 | ||||||||
| FaxNumber: | 8593363205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2021 | ||||||||
| LastUpdateDate: | 10/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 256116 | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.