1023019932 NPI number — KENNETH A STREET LPC

Table of content: KENNETH A STREET LPC (NPI 1023019932)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023019932 NPI number — KENNETH A STREET LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STREET
Provider First Name:
KENNETH
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STREET
Provider Other First Name:
ANDY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1023019932
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3413 RAINBOW PKWY STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RAINBOW CITY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35906-3234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-490-6423
Provider Business Mailing Address Fax Number:
256-380-5857

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3413 RAINBOW PKWY STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAINBOW CITY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35906-3234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-490-6423
Provider Business Practice Location Address Fax Number:
256-380-5857
Provider Enumeration Date:
08/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  2004 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2004 . This is a "LPC" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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