Provider Demographics
NPI:1306496229
Name:DEW, KENNESSE
Entity type:Individual
Prefix:
First Name:KENNESSE
Middle Name:
Last Name:DEW
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 1:6314 BIRCHWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32448-5202
Mailing Address - Country:US
Mailing Address - Phone:850-272-5764
Mailing Address - Fax:
Practice Address - Street 1:10611 NW SR 20
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:FL
Practice Address - Zip Code:32321
Practice Address - Country:US
Practice Address - Phone:850-643-1033
Practice Address - Fax:850-643-5066
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW13452104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker