Provider Demographics
NPI:1952816381
Name:HARTMAN, KENNETH LEROY (LCSW)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:LEROY
Last Name:HARTMAN
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 1:1338 WESTEN ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3365
Mailing Address - Country:US
Mailing Address - Phone:270-392-5531
Mailing Address - Fax:270-599-0399
Practice Address - Street 1:1338 WESTEN ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3365
Practice Address - Country:US
Practice Address - Phone:270-392-5531
Practice Address - Fax:270-599-0399
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-07
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2535341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100403710Medicaid