Provider Demographics
NPI:1669140562
Name:SUMMERS, KEN JAMES (MS, LMFT)
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:JAMES
Last Name:SUMMERS
Suffix:
Gender:M
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 BROADMOOR DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-6111
Mailing Address - Country:US
Mailing Address - Phone:309-846-5901
Mailing Address - Fax:
Practice Address - Street 1:3101 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-8465
Practice Address - Country:US
Practice Address - Phone:308-846-5901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166.000929106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist