Provider Demographics
NPI:1326755729
Name:DURHAM, KENTON
Entity Type:Individual
Prefix:
First Name:KENTON
Middle Name:
Last Name:DURHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2960 W ENON RD
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-8548
Mailing Address - Country:US
Mailing Address - Phone:937-272-4925
Mailing Address - Fax:937-984-4346
Practice Address - Street 1:2960 W ENON RD
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-8548
Practice Address - Country:US
Practice Address - Phone:937-272-4925
Practice Address - Fax:937-984-4346
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-04
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.182506101YA0400X
OHCDCA.186062101YA0400X
OHM.2400388-TRNE101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0002801Medicaid