Provider Demographics
NPI:1770863847
Name:SABIA, KENNETH MICHAEL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:SABIA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1028 S BISHOP AVE
Mailing Address - Street 2:SUITE 154
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-4416
Mailing Address - Country:US
Mailing Address - Phone:573-465-3338
Mailing Address - Fax:
Practice Address - Street 1:1028 S BISHOP AVE
Practice Address - Street 2:SUITE 154
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-4416
Practice Address - Country:US
Practice Address - Phone:573-465-3338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20100246091041C0700X
FLSW75381041C0700X
NY0216371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU3306Medicare UPIN