Provider Demographics
NPI:1023176815
Name:CURTIS, KEN (LSWI)
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:CURTIS
Suffix:
Gender:M
Credentials:LSWI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1914 N SUMMERWIND PL
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-3463
Mailing Address - Country:US
Mailing Address - Phone:208-922-9001
Mailing Address - Fax:208-922-3778
Practice Address - Street 1:190 W. MAIN STREET
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634
Practice Address - Country:US
Practice Address - Phone:208-922-9001
Practice Address - Fax:208-922-3778
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSWI-27227104100000X
IDLPC-4819101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806162000Medicaid