Provider Demographics
NPI:1477864072
Name:MARCINIAK, KENNETH ERNEST (AUD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ERNEST
Last Name:MARCINIAK
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1010 OLD DES PERES RD
Mailing Address - Street 2:
Mailing Address - City:DES PERES
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1865
Mailing Address - Country:US
Mailing Address - Phone:314-722-4280
Mailing Address - Fax:314-729-0101
Practice Address - Street 1:607 S NEW BALLAS RD STE 2300
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8234
Practice Address - Country:US
Practice Address - Phone:314-251-6394
Practice Address - Fax:314-251-4235
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010020892231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1477864072Medicaid