Provider Demographics
NPI:1972893436
Name:KENNETH, VERNA ANN (BA, LSAA, CMS)
Entity Type:Individual
Prefix:MS
First Name:VERNA
Middle Name:ANN
Last Name:KENNETH
Suffix:
Gender:F
Credentials:BA, LSAA, CMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 1144
Mailing Address - Street 2:SOUTHWEST HIGHLAND DRIVE
Mailing Address - City:CROWNPOINT
Mailing Address - State:NM
Mailing Address - Zip Code:87313-1144
Mailing Address - Country:US
Mailing Address - Phone:505-786-2111
Mailing Address - Fax:505-786-5442
Practice Address - Street 1:NORTH 371 SOUTHWEST HIGHLAND DRIVE
Practice Address - Street 2:
Practice Address - City:CROWNPOINT
Practice Address - State:NM
Practice Address - Zip Code:87313
Practice Address - Country:US
Practice Address - Phone:505-786-2111
Practice Address - Fax:505-786-5442
Is Sole Proprietor?:No
Enumeration Date:2011-04-18
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0138591101Y00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1831397488OtherBHS