Provider Demographics
NPI:1669843330
Name:CROSS, KENNETH (M DIV, LMFT)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:CROSS
Suffix:
Gender:M
Credentials:M DIV, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 WHITLOCK AVE NW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-2342
Mailing Address - Country:US
Mailing Address - Phone:770-429-9293
Mailing Address - Fax:
Practice Address - Street 1:92 WHITLOCK AVE NW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-2342
Practice Address - Country:US
Practice Address - Phone:770-429-9293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001425106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist