Provider Demographics
NPI:1407020373
Name:GAYLE, KENNETH SCOTT (MS ED LCSW)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:SCOTT
Last Name:GAYLE
Suffix:
Gender:M
Credentials:MS ED LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1177
Mailing Address - Street 2:926 SOUTH 8TH STREET
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54221-1177
Mailing Address - Country:US
Mailing Address - Phone:920-683-4230
Mailing Address - Fax:920-683-4908
Practice Address - Street 1:926 SOUTH 8TH STREET
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54221-1177
Practice Address - Country:US
Practice Address - Phone:920-683-4230
Practice Address - Fax:920-683-4908
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20111231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39701500Medicaid