Provider Demographics
NPI:1548328156
Name:KENDALL, MARY JO (LMSW)
Entity type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:KENDALL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 MICHGAN AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:MI
Mailing Address - Zip Code:49304-7984
Mailing Address - Country:US
Mailing Address - Phone:231-745-4624
Mailing Address - Fax:231-745-5031
Practice Address - Street 1:1615 MICHGAN AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:MI
Practice Address - Zip Code:49304-7984
Practice Address - Country:US
Practice Address - Phone:231-745-4624
Practice Address - Fax:231-745-5031
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801066851104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
0N78750004Medicare ID - Type Unspecified