Healthcare Provider Details

I. General information

NPI: 1255502084
Provider Name (Legal Business Name): KENNETH JOSEPH LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2008
Last Update Date: 03/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 DANNON VW SW SUITE 3202
ATLANTA GA
30331-2157
US

IV. Provider business mailing address

920 DANNON VW SW SUITE 3202
ATLANTA GA
30331-2157
US

V. Phone/Fax

Practice location:
  • Phone: 404-346-3471
  • Fax:
Mailing address:
  • Phone: 404-346-3471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC004942
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: