Provider Demographics
NPI:1902210768
Name:HOLLOWAY, KENNETH (MPH, LCAC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:HOLLOWAY
Suffix:
Gender:M
Credentials:MPH, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2924 E DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4709
Mailing Address - Country:US
Mailing Address - Phone:316-265-8511
Mailing Address - Fax:316-265-5047
Practice Address - Street 1:2924 E DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4709
Practice Address - Country:US
Practice Address - Phone:316-265-8511
Practice Address - Fax:316-265-5047
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS168101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)