Kendra D Phoumivong, LMSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

CSW006876 Issued in GA

Practice address

690 Courtenay Dr NE
Atlanta, GA 30306-3421

Phone

(404) 875-4551

NPI assigned

May 24, 2016

Last updated

Jan 31, 2023By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other names 1

• Kendra Butler Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1464048000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1675123200000",
    "number": "1336596931",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5 SUMMER LAKE WAY",
            "city": "SAVANNAH",
            "state": "GA",
            "postal_code": "314073534",
            "telephone_number": "912-247-3969"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "690 COURTENAY DR NE",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303063421",
            "telephone_number": "404-875-4551"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PHOUMIVONG",
        "first_name": "KENDRA",
        "middle_name": "D",
        "credential": "LMSW",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2016-05-24",
        "last_updated": "2023-01-31",
        "certification_date": "2023-01-31",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "104100000X",
            "taxonomy_group": "",
            "desc": "Social Worker",
            "state": "AR",
            "license": "8033-M",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "AR",
            "license": "8033-C",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "GA",
            "license": "CSW006876",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "KENDRA",
            "last_name": "BUTLER",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

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• Clinical Social Worker in Atlanta, GA
• Providers in Atlanta, GA by specialty
• Clinical Social Worker in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 31, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.