Healthcare Provider Details

I. General information

NPI: 1588911499
Provider Name (Legal Business Name): KENNETH D DUDLEY LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2012
Last Update Date: 08/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 E 25TH ST
IDAHO FALLS ID
83404-7549
US

IV. Provider business mailing address

2420 E 25TH ST
IDAHO FALLS ID
83404-7549
US

V. Phone/Fax

Practice location:
  • Phone: 208-542-1026
  • Fax: 208-528-2945
Mailing address:
  • Phone: 208-542-1026
  • Fax: 208-528-2945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-5061
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: