Provider Demographics
NPI:1740069129
Name:MINDER, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:MINDER
Suffix:
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 1:11144 TESSON FERRY RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-6965
Mailing Address - Country:US
Mailing Address - Phone:314-729-1200
Mailing Address - Fax:314-729-1201
Practice Address - Street 1:11144 TESSON FERRY RD STE 101
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-6965
Practice Address - Country:US
Practice Address - Phone:314-729-1200
Practice Address - Fax:314-729-1201
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023034746101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional