Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | 20040382 | IN |
N | 103T00000X | Psychologist | 20040382 | IN |
N | 103TB0200X | Cognitive & Behavioral Psychologist | ||
N | 103G00000X | Clinical Psychologist | 20040382 | IN |
N | 103TC0700X | Clinical Psychologist | 20040382 | IN |
N | 103TC2200X | Clinical Child & Adolescent Psychologist | ||
N | 103TF0000X | Family Psychologist | ||
N | 103TF0200X | Forensic Psychologist | ||
N | 103TP2701X | Group Psychotherapist |
NPI | 1023007853 |
---|---|
Provider Name | Dr. David R. Kenis |
First Address | Valparaiso, IN 46383-1333 |
Second Address | Valparaiso, IN 46383-2512 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/10/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
R83150 | (02) |