Healthcare Provider Details

I. General information

NPI: 1770863847
Provider Name (Legal Business Name): KENNETH MICHAEL SABIA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2011
Last Update Date: 09/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1028 S BISHOP AVE SUITE 154
ROLLA MO
65401-4416
US

IV. Provider business mailing address

1028 S BISHOP AVE SUITE 154
ROLLA MO
65401-4416
US

V. Phone/Fax

Practice location:
  • Phone: 573-465-3338
  • Fax:
Mailing address:
  • Phone: 573-465-3338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2010024609
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW7538
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number021637
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: