Provider Demographics
NPI:1356828487
Name:MCDERMOTT, KENNETH LEE (TLLP)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:LEE
Last Name:MCDERMOTT
Suffix:
Gender:M
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 WASHTENAW AVE STE 265
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-4200
Mailing Address - Country:US
Mailing Address - Phone:734-822-4810
Mailing Address - Fax:
Practice Address - Street 1:3300 WASHTENAW AVE STE 265
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-4200
Practice Address - Country:US
Practice Address - Phone:734-822-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-21
Last Update Date:2023-08-30
Deactivation Date:2022-09-24
Deactivation Code:
Reactivation Date:2023-08-28
Provider Licenses
StateLicense IDTaxonomies
MI6362009637103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical