Basic Information
Provider Information
NPI: 1003803453
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LABASKY
FirstName: KENNETH
MiddleName: L
NamePrefix:  
NameSuffix:  
Credential: LCSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3300 ACADEMY AVE
Address2:  
City: PORTSMOUTH
State: VA
PostalCode: 237033205
CountryCode: US
TelephoneNumber: 7574836404
FaxNumber: 7574830737
Practice Location
Address1: 3300 ACADEMY AVE
Address2:  
City: PORTSMOUTH
State: VA
PostalCode: 237033205
CountryCode: US
TelephoneNumber: 7574836404
FaxNumber: 7574830737
Other Information
ProviderEnumerationDate: 09/30/2005
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: X
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700X0904000814VAY Behavioral Health & Social Service ProvidersSocial WorkerClinical

ID Information
IDTypeStateIssuerDescription
08070901VASENTARAOTHER
08797801VAANTHEMOTHER


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