Provider Demographics
NPI:1447470570
Name:GATES, KENNETH WESLEY (PSYD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WESLEY
Last Name:GATES
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1247 SUSSEX TPKE
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-2943
Mailing Address - Country:US
Mailing Address - Phone:973-540-9586
Mailing Address - Fax:973-895-1383
Practice Address - Street 1:1247 SUSSEX TPKE
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-2943
Practice Address - Country:US
Practice Address - Phone:973-540-9586
Practice Address - Fax:973-895-1383
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2092103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist