Provider Demographics
NPI:1649730284
Name:STERCK, KENNETH IRA (CAC2)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:IRA
Last Name:STERCK
Suffix:
Gender:M
Credentials:CAC2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2565 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3119
Mailing Address - Country:US
Mailing Address - Phone:719-663-7021
Mailing Address - Fax:719-632-3534
Practice Address - Street 1:2565 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3119
Practice Address - Country:US
Practice Address - Phone:719-663-7021
Practice Address - Fax:719-632-3534
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACB.0007918101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)