Provider Demographics
NPI:1528218864
Name:MCCOY, KENNETH LAMAR (LLMSW)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:LAMAR
Last Name:MCCOY
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4711 WALMA AVE SE
Mailing Address - Street 2:204
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49512-5250
Mailing Address - Country:US
Mailing Address - Phone:616-819-0295
Mailing Address - Fax:616-656-0193
Practice Address - Street 1:40 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4304
Practice Address - Country:US
Practice Address - Phone:616-456-1443
Practice Address - Fax:616-732-6392
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801085178/2172616104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker