Provider Demographics
NPI:1942439302
Name:PHELPS, KENNETH W (PHD, LMFT)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:W
Last Name:PHELPS
Suffix:
Gender:M
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 HARDEN STREET EXT
Mailing Address - Street 2:15 MEDICAL PARK, SUITE 141
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6894
Mailing Address - Country:US
Mailing Address - Phone:803-434-4221
Mailing Address - Fax:803-434-4351
Practice Address - Street 1:3555 HARDEN STREET EXT
Practice Address - Street 2:15 MEDICAL PARK, SUITE 141
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6894
Practice Address - Country:US
Practice Address - Phone:803-434-4221
Practice Address - Fax:803-434-4351
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4520106H00000X
NC1309106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCLT1001Medicaid