Healthcare Provider Details

I. General information

NPI: 1578821641
Provider Name (Legal Business Name): KENNETH B MASI PHD,
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W JEFFERSON ST
BLOOMINGTON IL
61701-3904
US

IV. Provider business mailing address

105 W JEFFERSON ST
BLOOMINGTON IL
61701-3904
US

V. Phone/Fax

Practice location:
  • Phone: 309-532-3700
  • Fax:
Mailing address:
  • Phone: 309-532-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: