Provider Demographics
NPI:1215947320
Name:FORMOSA, KENNETH J SR (MSW, LMSW)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:J
Last Name:FORMOSA
Suffix:SR
Gender:M
Credentials:MSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8416 BAYTES DR
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116
Mailing Address - Country:US
Mailing Address - Phone:734-751-5722
Mailing Address - Fax:
Practice Address - Street 1:ROMULAS HELP CENTER
Practice Address - Street 2:9430 WAYNE ROAD SUITE A
Practice Address - City:ROAMULAS
Practice Address - State:MI
Practice Address - Zip Code:48174
Practice Address - Country:US
Practice Address - Phone:734-942-7585
Practice Address - Fax:734-942-7977
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801069917104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker