| Doctor Name: | KENNETH LAMAR PRUST |
| NPI Number: | 1134113178 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LCSW |
| License Number: | 6795-123 |
| Business Practice Address: | 1200 N Center St Beaver Dam, WI - 539161148 |
| Business Phone Number: | 9208873171 |
| Business Fax Number: | 9208878662 |
| Mailing Address: | N7377 Malibou Ln, BEAVER DAM |
| State: | WI |
| Postal Code: | 539169534 |
| Phone Number: | 9208872517 |
| Fax Number: | 9208878662 |
| NPI Enumeration Date: | 09/06/2005 |
| NPI Last Update Date: | 07/09/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | 6795-123 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WI |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |