Provider Demographics
NPI:1427355312
Name:BABCOCK, KENNETH WAYNE (MSW,LICSW, QCSW,DCSW)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:WAYNE
Last Name:BABCOCK
Suffix:
Gender:M
Credentials:MSW,LICSW, QCSW,DCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 NONNAMAKER DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-7160
Mailing Address - Country:US
Mailing Address - Phone:425-238-4883
Mailing Address - Fax:
Practice Address - Street 1:265 NONNAMAKER DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-7160
Practice Address - Country:US
Practice Address - Phone:425-238-4883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-11
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW601766901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical