Provider Demographics
NPI:1992795223
Name:NINHAM, KENNETH R (MSE)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:NINHAM
Suffix:
Gender:M
Credentials:MSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 OLD ABE RD
Mailing Address - Street 2:
Mailing Address - City:LAC DU FLAMBEAU
Mailing Address - State:WI
Mailing Address - Zip Code:54538-9386
Mailing Address - Country:US
Mailing Address - Phone:715-588-3371
Mailing Address - Fax:715-588-2031
Practice Address - Street 1:129 OLD ABE RD
Practice Address - Street 2:
Practice Address - City:LAC DU FLAMBEAU
Practice Address - State:WI
Practice Address - Zip Code:54538-9386
Practice Address - Country:US
Practice Address - Phone:715-588-3371
Practice Address - Fax:715-588-2031
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2624-120101YM0800X
WI11915-134101YP2500X
WI1060-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39231600Medicaid