Provider Demographics
NPI:1932154887
Name:GATES, KENNETH WAYNE (M SW)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:WAYNE
Last Name:GATES
Suffix:
Gender:M
Credentials:M SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 WHITE HALL RD
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-3850
Mailing Address - Country:US
Mailing Address - Phone:254-776-1393
Mailing Address - Fax:
Practice Address - Street 1:4800 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76711-1329
Practice Address - Country:US
Practice Address - Phone:254-356-5297
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14494104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker