Provider Demographics
NPI:1093531402
Name:KIDRICK, KENNEDY R
Entity type:Individual
Prefix:
First Name:KENNEDY
Middle Name:R
Last Name:KIDRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 S MARKET BLVD # 11
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-3043
Mailing Address - Country:US
Mailing Address - Phone:360-360-2195
Mailing Address - Fax:
Practice Address - Street 1:409 S MARKET BLVD # 11
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3043
Practice Address - Country:US
Practice Address - Phone:360-360-2195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61593286101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health