Provider Demographics
NPI:1275629685
Name:EDWARDS, KENNETH T JR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:T
Last Name:EDWARDS
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3430 NEWBURG RD
Mailing Address - Street 2:STE 210
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-2458
Mailing Address - Country:US
Mailing Address - Phone:502-454-8800
Mailing Address - Fax:502-736-0140
Practice Address - Street 1:3430 NEWBURG RD
Practice Address - Street 2:SUITE 212
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-2497
Practice Address - Country:US
Practice Address - Phone:502-454-8800
Practice Address - Fax:502-736-0140
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY06521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0768207Medicare ID - Type Unspecified