Basic Information
| Provider Information | |||||||||
| NPI: | 1033356423 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SERKOWNEK | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 770 SE KANE ST | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974703943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416730057 | ||||||||
| FaxNumber: | 5416732270 | ||||||||
| Practice Location | |||||||||
| Address1: | 770 SE KANE ST | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974703943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416730057 | ||||||||
| FaxNumber: | 5416732270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2009 | ||||||||
| LastUpdateDate: | 01/12/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | 587 | OR | Y | Behavioral Health & Social Service Providers | Psychologist | Counseling |
No ID Information.