Provider Demographics
NPI:1407990641
Name:SIPE, KENNETH L (LICSW)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:L
Last Name:SIPE
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 WESTON RD
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-2346
Mailing Address - Country:US
Mailing Address - Phone:781-710-8873
Mailing Address - Fax:781-237-6954
Practice Address - Street 1:592A WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482-6417
Practice Address - Country:US
Practice Address - Phone:781-710-8873
Practice Address - Fax:781-237-6954
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALICSW 1005471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP01254 80Medicare ID - Type Unspecified