Provider Demographics
NPI:1285173179
Name:STAHL, KENNETH (LPCC-S, LICDC)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:STAHL
Suffix:
Gender:M
Credentials:LPCC-S, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4879 US HIGHWAY 68 S
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:OH
Mailing Address - Zip Code:43357-9525
Mailing Address - Country:US
Mailing Address - Phone:937-599-1411
Mailing Address - Fax:937-599-4128
Practice Address - Street 1:4879 US HIGHWAY 68 S
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:OH
Practice Address - Zip Code:43357
Practice Address - Country:US
Practice Address - Phone:937-599-1411
Practice Address - Fax:937-599-4128
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.161786101YA0400X
OHE1700041-SUPV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0213436Medicaid