Provider Demographics
NPI:1578643169
Name:RAPP, KENNETH M (LLP)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:RAPP
Suffix:
Gender:M
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3435 WATERFORD CT NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-2641
Mailing Address - Country:US
Mailing Address - Phone:616-361-5688
Mailing Address - Fax:
Practice Address - Street 1:611 N STATE ST
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:MI
Practice Address - Zip Code:48888-9702
Practice Address - Country:US
Practice Address - Phone:989-831-7542
Practice Address - Fax:989-831-7578
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007891103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1715928Medicaid