Provider Demographics
NPI:1902046477
Name:TRIPP, KEN A (LMSW, CASAC)
Entity Type:Individual
Prefix:MR
First Name:KEN
Middle Name:A
Last Name:TRIPP
Suffix:
Gender:M
Credentials:LMSW, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3019 COUNTY COMPLEX DR
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-9505
Mailing Address - Country:US
Mailing Address - Phone:585-396-4190
Mailing Address - Fax:
Practice Address - Street 1:3019 COUNTY COMPLEX DR
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-9505
Practice Address - Country:US
Practice Address - Phone:585-396-4190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-24
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0790011041C0700X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)