Provider Demographics
NPI:1558319731
Name:WEEDEN, KENNETH ARNOLD JR (LCDP , CCDPD)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ARNOLD
Last Name:WEEDEN
Suffix:JR
Gender:M
Credentials:LCDP , CCDPD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 WAMPANOAG TRL
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-1504
Mailing Address - Country:US
Mailing Address - Phone:401-431-9870
Mailing Address - Fax:401-438-1957
Practice Address - Street 1:610 WAMPANOAG TRL
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02915-1504
Practice Address - Country:US
Practice Address - Phone:401-431-9870
Practice Address - Fax:401-438-1957
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICDP00467101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI101YA0400XOtherRI DEPT. OF HEALTH
RIKW31753Medicaid