Healthcare Provider Details

I. General information

NPI: 1902046477
Provider Name (Legal Business Name): KEN A TRIPP LMSW, CASAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2009
Last Update Date: 12/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3019 COUNTY COMPLEX DR
CANANDAIGUA NY
14424-9505
US

IV. Provider business mailing address

3019 COUNTY COMPLEX DR
CANANDAIGUA NY
14424-9505
US

V. Phone/Fax

Practice location:
  • Phone: 585-396-4190
  • Fax:
Mailing address:
  • Phone: 585-396-4190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number079001
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: