Healthcare Provider Details

I. General information

NPI: 1598940520
Provider Name (Legal Business Name): KEN MACANKA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2008
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 W FORT ST FL 2
BOISE ID
83702-4535
US

IV. Provider business mailing address

419 CENTER RD
EASTON CT
06612-1649
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1018
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number01291963
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: