Provider Demographics
NPI:1730968504
Name:MIKLOS, KENDRA (LSW, LCACA)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:MIKLOS
Suffix:
Gender:F
Credentials:LSW, LCACA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4619 BEAVER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-2901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 LAKE AVE
Practice Address - Street 2:260
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5351
Practice Address - Country:US
Practice Address - Phone:260-424-0411
Practice Address - Fax:260-424-3530
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33011221A104100000X
IN87900086A101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker