Provider Demographics
NPI:1568525202
Name:FRONTMAN, KENNETH CHARLES (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:CHARLES
Last Name:FRONTMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11285 ELKINS RD
Mailing Address - Street 2:STE D3
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-5835
Mailing Address - Country:US
Mailing Address - Phone:770-559-9752
Mailing Address - Fax:770-592-0510
Practice Address - Street 1:1150 UPPER HEMBREE ROAD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1142
Practice Address - Country:US
Practice Address - Phone:678-624-0930
Practice Address - Fax:678-624-0730
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-17
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001835103TC0700X
GA1835103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00672526BMedicaid