Provider Demographics
NPI:1316518319
Name:HOMAN, KENDALL
Entity type:Individual
Prefix:
First Name:KENDALL
Middle Name:
Last Name:HOMAN
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 1:2025 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:FORTVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46040-9252
Mailing Address - Country:US
Mailing Address - Phone:765-621-6670
Mailing Address - Fax:
Practice Address - Street 1:401 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:INGALLS
Practice Address - State:IN
Practice Address - Zip Code:46048-9500
Practice Address - Country:US
Practice Address - Phone:765-621-6670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-09
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
IN33010822A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst