Basic Information
| Provider Information | |||||||||
| NPI: | 1003366261 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOVE | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11326 GODDARD CT | ||||||||
| Address2: | |||||||||
| City: | TAYLOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481806218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343248326 | ||||||||
| FaxNumber: | 7343248327 | ||||||||
| Practice Location | |||||||||
| Address1: | 14799 DIX TOLEDO RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481952507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343248326 | ||||||||
| FaxNumber: | 7343248327 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2016 | ||||||||
| LastUpdateDate: | 10/11/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.