Provider Demographics
NPI:1134113178
Name:PRUST, KENNETH LAMAR (LCSW)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:LAMAR
Last Name:PRUST
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N7377 MALIBOU LN
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-9534
Mailing Address - Country:US
Mailing Address - Phone:920-887-2517
Mailing Address - Fax:920-887-8662
Practice Address - Street 1:1200 N CENTER ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-1148
Practice Address - Country:US
Practice Address - Phone:920-887-3171
Practice Address - Fax:920-887-8662
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6795-123101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43579800Medicaid
WI00048872Medicare ID - Type UnspecifiedPROVIDER NUMBER