Provider Demographics
NPI:1659673515
Name:BECKER, KENNETH PAUL (LADC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:PAUL
Last Name:BECKER
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4048 LAKELAND AVE N # 22031
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2236
Mailing Address - Country:US
Mailing Address - Phone:612-325-8357
Mailing Address - Fax:
Practice Address - Street 1:4048 LAKELAND AVE N # 22031
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55422-2236
Practice Address - Country:US
Practice Address - Phone:612-325-8357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-29
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1035173-1-CDT101YA0400X
MN520101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)