Provider Demographics
NPI:1649321324
Name:BANCROFT, KENNETH M (LPCC-S, LICDC-CS)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:BANCROFT
Suffix:
Gender:M
Credentials:LPCC-S, LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44481-1141
Mailing Address - Country:US
Mailing Address - Phone:330-399-6451
Mailing Address - Fax:330-934-6266
Practice Address - Street 1:150 E MARKET ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44481-1141
Practice Address - Country:US
Practice Address - Phone:330-399-6451
Practice Address - Fax:330-934-6266
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH081074101YA0400X
OHS12092104100000X
OHE0002540-SUPV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000125407OtherANTHEM
OH539304000OtherMAGELLAN