Individual
KENNETH LAMAR PRUST
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
LCSW
Contact information
Practice address
1200 N CENTER ST, BEAVER DAM, WI 53916-1148
(920) 887-3171
(920) 887-8662
Mailing address
N7377 MALIBOU LN, BEAVER DAM, WI 53916-9534
(920) 887-2517
(920) 887-8662
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
6795-123
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
43579800
—
WI
Enumeration date
09/06/2005
Last updated
07/09/2007
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