Provider Demographics
NPI:1548374945
Name:MILLS, KENNETH RAYMOND (PHD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RAYMOND
Last Name:MILLS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1531 AIRPORT RD
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-8210
Mailing Address - Country:US
Mailing Address - Phone:515-233-4200
Mailing Address - Fax:515-233-4200
Practice Address - Street 1:1531 AIRPORT RD
Practice Address - Street 2:SUITE ONE
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-8210
Practice Address - Country:US
Practice Address - Phone:515-233-4200
Practice Address - Fax:515-233-4200
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00722103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA39966OtherWELLMARK
IA55357Medicare ID - Type Unspecified