Provider Demographics
NPI:1033356423
Name:SERKOWNEK, KENNETH EDWARD (PHD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:EDWARD
Last Name:SERKOWNEK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 SE KANE ST
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-3943
Mailing Address - Country:US
Mailing Address - Phone:541-673-0057
Mailing Address - Fax:541-673-2270
Practice Address - Street 1:770 SE KANE ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3943
Practice Address - Country:US
Practice Address - Phone:541-673-0057
Practice Address - Fax:541-673-2270
Is Sole Proprietor?:No
Enumeration Date:2009-01-07
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR587103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling