Provider Demographics
NPI:1174311500
Name:KIRK, KENNETH ANDREW
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:ANDREW
Last Name:KIRK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43114 HUNTSMAN SQ
Mailing Address - Street 2:
Mailing Address - City:BROADLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:20148-5091
Mailing Address - Country:US
Mailing Address - Phone:703-405-4315
Mailing Address - Fax:
Practice Address - Street 1:19415 DEERFIELD AVE STE 316
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-8472
Practice Address - Country:US
Practice Address - Phone:571-831-0999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-26
Last Update Date:2025-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health