Provider Demographics
NPI:1437481009
Name:QUEEN, KENNETH GALEN (MED, LCPC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:GALEN
Last Name:QUEEN
Suffix:
Gender:M
Credentials:MED, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 W. WILLOW KNOLLS DR.
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614
Mailing Address - Country:US
Mailing Address - Phone:309-681-5652
Mailing Address - Fax:309-681-5658
Practice Address - Street 1:3020 W. WILLOW KNOLLS DR.
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-681-5652
Practice Address - Fax:309-681-5658
Is Sole Proprietor?:No
Enumeration Date:2010-02-08
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.006438101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health