Provider Demographics
NPI:1437897204
Name:HISS, KENADID
Entity Type:Individual
Prefix:
First Name:KENADID
Middle Name:
Last Name:HISS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 W 31ST ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-3105
Mailing Address - Country:US
Mailing Address - Phone:612-426-8484
Mailing Address - Fax:
Practice Address - Street 1:4001 STINSON BLVD NE STE 314
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55421-3424
Practice Address - Country:US
Practice Address - Phone:612-298-7636
Practice Address - Fax:612-354-3801
Is Sole Proprietor?:No
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician