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General NPI Number Information
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NPI Number | 1104869528
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Entity Type | Individual
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Provider Name | KENNETH B. LITTLE M.A.
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Gender | Male
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Dates
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Enumeration Date | 06/14/2006
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Last Update Date | 08/19/2019
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Provider Practice Location Address
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Address Line | 1935 COUNTY ROAD B2 W STE 120
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City | ROSEVILLE
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State | MN
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Zip | 55113-2722
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Country | US
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Telephone | 651-964-0235
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Fax | 651-340-5652
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Provider Business Mailing Address
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Address Line | 5505 INTERLACHEN BLVD
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City | EDINA
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State | MN
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Zip | 55436-1322
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Country | US
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Telephone | 952-300-7074
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | LP0568
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License Number State | MN
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