Provider Demographics
NPI:1194990614
Name:NYDAM, KENNETH JOHN (LMSW)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOHN
Last Name:NYDAM
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5839 HOPE WAY
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-7085
Mailing Address - Country:US
Mailing Address - Phone:231-942-8455
Mailing Address - Fax:
Practice Address - Street 1:5839 HOPE WAY
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-7085
Practice Address - Country:US
Practice Address - Phone:231-942-8455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical