Provider Demographics
NPI:1144278714
Name:KENNEL, WANDA MARIE (LCDC, LSBW)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:MARIE
Last Name:KENNEL
Suffix:
Gender:F
Credentials:LCDC, LSBW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6563 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:GILMER
Mailing Address - State:TX
Mailing Address - Zip Code:75645-8279
Mailing Address - Country:US
Mailing Address - Phone:903-734-5592
Mailing Address - Fax:
Practice Address - Street 1:6563 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:GILMER
Practice Address - State:TX
Practice Address - Zip Code:75645-8279
Practice Address - Country:US
Practice Address - Phone:903-734-5592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5922101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5922OtherLCDC
TXS23305OtherLBSW