Provider Demographics
NPI:1407263593
Name:DANDRIDGE, KENETRA DEVONNE (LCMHC, LCAS, CCS)
Entity type:Individual
Prefix:
First Name:KENETRA
Middle Name:DEVONNE
Last Name:DANDRIDGE
Suffix:
Gender:
Credentials:LCMHC, LCAS, CCS
Other - Prefix:
Other - First Name:K
Other - Middle Name:DEVONNE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCAS, LCMHC,CCS
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 RANDOLPH RD STE 800
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1110
Practice Address - Country:US
Practice Address - Phone:704-384-1246
Practice Address - Fax:704-384-6072
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20215101YA0400X
101YA0400X
NC15759101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC21286Medicaid