Provider Demographics
NPI:1932200417
Name:GOODROW, KENNETH KRISS II (MS, LPCC, NCC, CCMHC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:KRISS
Last Name:GOODROW
Suffix:II
Gender:M
Credentials:MS, LPCC, NCC, CCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3949 CORRALES RD # 240B
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-9348
Mailing Address - Country:US
Mailing Address - Phone:505-239-7459
Mailing Address - Fax:505-899-4060
Practice Address - Street 1:3949 CORRALES RD # 240B
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048
Practice Address - Country:US
Practice Address - Phone:505-239-7459
Practice Address - Fax:505-899-4060
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0078151251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM09881522Medicaid