Provider Demographics
NPI:1225191976
Name:WADUM, KENNETH CHARLES (EDD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:CHARLES
Last Name:WADUM
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 18TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-1018
Mailing Address - Country:US
Mailing Address - Phone:507-282-8029
Mailing Address - Fax:507-280-8780
Practice Address - Street 1:1700 N BROADWAY
Practice Address - Street 2:SUITE 118
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55906-4144
Practice Address - Country:US
Practice Address - Phone:507-280-0225
Practice Address - Fax:507-280-8780
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2777103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical