Provider Demographics
NPI:1104869528
Name:LITTLE, KENNETH B (MA)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:B
Last Name:LITTLE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5505 INTERLACHEN BLVD
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55436-1322
Mailing Address - Country:US
Mailing Address - Phone:952-300-7074
Mailing Address - Fax:
Practice Address - Street 1:1935 COUNTY ROAD B2 W STE 120
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-2722
Practice Address - Country:US
Practice Address - Phone:651-964-0235
Practice Address - Fax:651-340-5652
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0568103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1032815OtherPREFERREDONE
MN229D0LIOtherBLUE SHIELD OF MINNESOTA
MN143646OtherUCARE MINNESOTA
MNHP50066OtherHEALTHPARTNERS
MN62-47135OtherUNITED BEHAVIORAL HEALTH
MN976847500Medicaid