Provider Demographics
NPI:1962258707
Name:FOX, KENNERLY
Entity type:Individual
Prefix:
First Name:KENNERLY
Middle Name:
Last Name:FOX
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 1:1650 COUNTY SERVICES PKWY SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30008-4010
Mailing Address - Country:US
Mailing Address - Phone:404-823-3308
Mailing Address - Fax:
Practice Address - Street 1:1650 COUNTY SERVICES PKWY SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30008-4010
Practice Address - Country:US
Practice Address - Phone:404-823-3308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC014635101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health