Provider Demographics
NPI:1962466714
Name:YEAGER, KENNETH R (LISW)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:YEAGER
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1670 UPHAM DR.
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1250
Mailing Address - Country:US
Mailing Address - Phone:614-293-9600
Mailing Address - Fax:614-293-9467
Practice Address - Street 1:1670 UPHAM DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1250
Practice Address - Country:US
Practice Address - Phone:614-293-9600
Practice Address - Fax:614-293-9467
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH8825031041C0700X
OH1-00092141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P46882Medicare UPIN
YESW24291Medicare PIN