Provider Demographics
NPI:1336482215
Name:DEBLOCK, KENNETH MARTIN (LPC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:MARTIN
Last Name:DEBLOCK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 N TWYMAN RD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64058-3211
Mailing Address - Country:US
Mailing Address - Phone:816-249-5371
Mailing Address - Fax:
Practice Address - Street 1:3205 N TWYMAN RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64058-3211
Practice Address - Country:US
Practice Address - Phone:816-249-5371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-29
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013008640101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2013008640OtherPLPC