Provider Demographics
NPI:1659793867
Name:LOCKE, KENNETH (PHD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:LOCKE
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 1:121 W SWEET AVE
Mailing Address - Street 2:UNIVERSITY OF IDAHO - CHILD & YOUTH STUDY CENTER
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83844-4061
Mailing Address - Country:US
Mailing Address - Phone:208-885-6191
Mailing Address - Fax:208-885-6188
Practice Address - Street 1:121 W SWEET AVE
Practice Address - Street 2:UNIVERSITY OF IDAHO - CHILD & YOUTH STUDY CENTER
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83844-4061
Practice Address - Country:US
Practice Address - Phone:208-885-6191
Practice Address - Fax:208-885-6188
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202758103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical