Provider Demographics
NPI:1457447765
Name:DITTMAR, KENNETH (M S)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:DITTMAR
Suffix:
Gender:M
Credentials:M S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 BRADFORD AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-5401
Mailing Address - Country:US
Mailing Address - Phone:910-323-2311
Mailing Address - Fax:
Practice Address - Street 1:711 EXECUTIVE PL
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5193
Practice Address - Country:US
Practice Address - Phone:910-222-6357
Practice Address - Fax:910-678-9963
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC503103TC0700X
NC459106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107330Medicaid