Provider Demographics
NPI:1154505071
Name:REID, KENNETH EDWARD (PHD, LMSW)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:EDWARD
Last Name:REID
Suffix:
Gender:M
Credentials:PHD, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3830 FERNDALE AVE.
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001
Mailing Address - Country:US
Mailing Address - Phone:269-345-3962
Mailing Address - Fax:269-381-7067
Practice Address - Street 1:5220 LOVERS LANE
Practice Address - Street 2:LL 100
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002
Practice Address - Country:US
Practice Address - Phone:269-381-4442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010060571041C0700X
MI4101000350106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist