Provider Demographics
NPI:1851917413
Name:FAUSETT, KENNETH WILLIAM SR (LMFT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:WILLIAM
Last Name:FAUSETT
Suffix:SR
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:276 LAKE HAVASU AVE S APT C32
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6521
Mailing Address - Country:US
Mailing Address - Phone:928-813-8977
Mailing Address - Fax:
Practice Address - Street 1:276 LAKE HAVASU AVE S APT C32
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6521
Practice Address - Country:US
Practice Address - Phone:928-813-8977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-19
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMFT-15484106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist