Provider Demographics
NPI:1295311587
Name:NEWSOME, KENNETH E JR
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:E
Last Name:NEWSOME
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2826 N. MONROE ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526
Mailing Address - Country:US
Mailing Address - Phone:708-771-7180
Mailing Address - Fax:
Practice Address - Street 1:1764 VALLEY RD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7112
Practice Address - Country:US
Practice Address - Phone:131-280-6751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health