Provider Demographics
NPI:1922730563
Name:MEDVE, KENNETH ANDREW (LCSW)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ANDREW
Last Name:MEDVE
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 1:2601 CROSS COUNTRY DR STE 900
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906-1801
Mailing Address - Country:US
Mailing Address - Phone:706-596-7170
Mailing Address - Fax:
Practice Address - Street 1:2601 CROSS COUNTRY DR STE 900
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-1801
Practice Address - Country:US
Practice Address - Phone:706-596-7170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0073291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty