Healthcare Provider Details

I. General information

NPI: 1336326172
Provider Name (Legal Business Name): KENNETH STANTON BJORK II LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

105 W RIVERSIDE DR
AUSTIN TX
78704-1247
US

IV. Provider business mailing address

1430 COLLIER ST
AUSTIN TX
78704-2911
US

V. Phone/Fax

Practice location:
  • Phone: 512-804-3000
  • Fax:
Mailing address:
  • Phone: 512-445-7787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34289
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: