Provider Demographics
NPI:1700188216
Name:MCDONNELL, KENNETH NEIL JR (LADC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:NEIL
Last Name:MCDONNELL
Suffix:JR
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 1:413 COMMERCIAL AVE N
Mailing Address - Street 2:
Mailing Address - City:SANDSTONE
Mailing Address - State:MN
Mailing Address - Zip Code:55072-4412
Mailing Address - Country:US
Mailing Address - Phone:320-245-9966
Mailing Address - Fax:651-408-7131
Practice Address - Street 1:413 COMMERCIAL AVE N
Practice Address - Street 2:
Practice Address - City:SANDSTONE
Practice Address - State:MN
Practice Address - Zip Code:55072-4412
Practice Address - Country:US
Practice Address - Phone:320-245-9966
Practice Address - Fax:651-408-7131
Is Sole Proprietor?:No
Enumeration Date:2010-12-03
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301667101YA0400X
MNLPC00934101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)