Basic Information
| Provider Information | |||||||||
| NPI: | 1144346156 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOUD | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | L.P.C., L.M.F.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LOUD | ||||||||
| OtherFirstName: | K. | ||||||||
| OtherMiddleName: | WAYNE | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | L.P.C., L.M.F.T. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 390 9TH ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974399470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419977134 | ||||||||
| FaxNumber: | 5419027528 | ||||||||
| Practice Location | |||||||||
| Address1: | 390 9TH ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974399470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419977134 | ||||||||
| FaxNumber: | 5419027528 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 03/30/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | C2024 | OR | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | T0553 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 273263 | 05 | OR | MEDICAID |