Provider Demographics
NPI:1902821499
Name:KISH, KENNETH A (LMSW, LMFT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:KISH
Suffix:
Gender:M
Credentials:LMSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5671 N SKEEL AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:OSCODA
Mailing Address - State:MI
Mailing Address - Zip Code:48750-1535
Mailing Address - Country:US
Mailing Address - Phone:989-747-0026
Mailing Address - Fax:989-747-0029
Practice Address - Street 1:5671 N SKEEL AVE STE 4
Practice Address - Street 2:
Practice Address - City:OSCODA
Practice Address - State:MI
Practice Address - Zip Code:48750-1535
Practice Address - Country:US
Practice Address - Phone:989-747-0026
Practice Address - Fax:989-747-0029
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801014727104100000X
MI4101005482106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist