Provider Demographics
NPI:1902566318
Name:KENNON, ANGELINA MARIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ANGELINA
Middle Name:MARIE
Last Name:KENNON
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 1:4247 MELS PL
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-7508
Mailing Address - Country:US
Mailing Address - Phone:541-891-0438
Mailing Address - Fax:
Practice Address - Street 1:4247 MELS PL
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-7508
Practice Address - Country:US
Practice Address - Phone:541-891-0438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-27
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL107871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical