Provider Demographics
NPI:1043561335
Name:KEN WADUM, ED.D. LP
Entity Type:Organization
Organization Name:KEN WADUM, ED.D. LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:WADUM
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:507-280-0225
Mailing Address - Street 1:1530 GREENVIEW DR SW
Mailing Address - Street 2:SUITE 207
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-4286
Mailing Address - Country:US
Mailing Address - Phone:507-280-0225
Mailing Address - Fax:
Practice Address - Street 1:1530 GREENVIEW DR SW
Practice Address - Street 2:SUITE 207
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902-4286
Practice Address - Country:US
Practice Address - Phone:507-280-0225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KEN WADUM, ED.D., LP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2777103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty