Provider Demographics
NPI:1376837419
Name:MEISEL, KENNETH J (LMSW)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:MEISEL
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22811 MACK AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2053
Mailing Address - Country:US
Mailing Address - Phone:586-774-9303
Mailing Address - Fax:
Practice Address - Street 1:22811 MACK AVE STE 107
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2053
Practice Address - Country:US
Practice Address - Phone:586-774-9303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010651871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical