Provider Demographics
NPI:1962283770
Name:MINA, KENDRA (LCSW)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:MINA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 HIXSON PIKE APT 207
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-3202
Mailing Address - Country:US
Mailing Address - Phone:423-521-2735
Mailing Address - Fax:
Practice Address - Street 1:3309 CUMMINGS HWY STE 110
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37419-2438
Practice Address - Country:US
Practice Address - Phone:423-521-2735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-09
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN91321041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty