Basic Information
| Provider Information | |||||||||
| NPI: | 1942439302 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHELPS | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD, LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3555 HARDEN STREET EXT | ||||||||
| Address2: | 15 MEDICAL PARK, SUITE 141 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034344221 | ||||||||
| FaxNumber: | 8034344351 | ||||||||
| Practice Location | |||||||||
| Address1: | 3555 HARDEN STREET EXT | ||||||||
| Address2: | 15 MEDICAL PARK, SUITE 141 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034344221 | ||||||||
| FaxNumber: | 8034344351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2009 | ||||||||
| LastUpdateDate: | 11/12/2010 | ||||||||
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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 | 106H00000X | 4520 | SC | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 1309 | NC | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | LT1001 | 05 | SC | MEDICAID |