Provider Demographics
NPI:1124187497
Name:MCDONALD, WILLIAM KENNETH (MDIV, LMSW)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:KENNETH
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:MDIV, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 N RIVER ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3800
Mailing Address - Country:US
Mailing Address - Phone:810-629-0760
Mailing Address - Fax:810-616-6268
Practice Address - Street 1:129 N RIVER ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3800
Practice Address - Country:US
Practice Address - Phone:810-629-0760
Practice Address - Fax:810-616-6268
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010040001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11652509OtherCAQH PROVIDER ID