Provider Demographics
NPI:1003170838
Name:FOURNIER, KENNETH GEORGE (LICSW)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:GEORGE
Last Name:FOURNIER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N. HIGHWAY 89
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86313-0000
Mailing Address - Country:US
Mailing Address - Phone:928-445-4860
Mailing Address - Fax:928-445-6116
Practice Address - Street 1:500 N US HIGHWAY 89
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86313-5001
Practice Address - Country:US
Practice Address - Phone:928-445-4860
Practice Address - Fax:928-776-6116
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN54161041C0700X
AZ135431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical