Provider Demographics
NPI:1376892364
Name:ADAMS, KENNETH MARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MARK
Last Name:ADAMS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26862 WOODWARD AVE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-0957
Mailing Address - Country:US
Mailing Address - Phone:248-398-0740
Mailing Address - Fax:248-398-9456
Practice Address - Street 1:26862 WOODWARD AVE
Practice Address - Street 2:SUITE 212
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-0957
Practice Address - Country:US
Practice Address - Phone:248-398-0740
Practice Address - Fax:248-398-9456
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005372103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist