Basic Information
| Provider Information | |||||||||
| NPI: | 1518055474 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DRUDE | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1130 VESTER AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 455037302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373903800 | ||||||||
| FaxNumber: | 9373903804 | ||||||||
| Practice Location | |||||||||
| Address1: | 1130 VESTER AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 455037302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373903800 | ||||||||
| FaxNumber: | 9373903804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 10/25/2007 | ||||||||
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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 | 103TC0700X | 1437 | OH | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0254577 | 05 | OH | MEDICAID |