Provider Demographics
NPI:1003053646
Name:ROBERT J KENNERLEY PHD PA
Entity Type:Organization
Organization Name:ROBERT J KENNERLEY PHD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:KENNERLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:386-423-9161
Mailing Address - Street 1:265 N CAUSEWAY
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32169-5239
Mailing Address - Country:US
Mailing Address - Phone:386-423-9161
Mailing Address - Fax:386-423-3094
Practice Address - Street 1:265 N CAUSEWAY
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32169-5239
Practice Address - Country:US
Practice Address - Phone:386-423-9161
Practice Address - Fax:386-423-3094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-20
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6507261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health