Provider Demographics
NPI:1770636128
Name:MACHADO, KENNETH A
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:MACHADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 DRIFT RD
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:MA
Mailing Address - Zip Code:02790
Mailing Address - Country:US
Mailing Address - Phone:508-636-4360
Mailing Address - Fax:
Practice Address - Street 1:1563 NORTH MAIN STREET SUITE 208
Practice Address - Street 2:SOUTH BAY MENTAL HEALTH CENTER
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720
Practice Address - Country:US
Practice Address - Phone:508-324-1060
Practice Address - Fax:508-672-3619
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2056651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical