Provider Demographics
NPI:1083663835
Name:PERNICANO, KEVIN MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:PERNICANO
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 1:2071 WIND CHIME WAY
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130
Mailing Address - Country:US
Mailing Address - Phone:210-278-4584
Mailing Address - Fax:
Practice Address - Street 1:8800 VILLAGE DRIVE
Practice Address - Street 2:STE 209
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217
Practice Address - Country:US
Practice Address - Phone:210-202-0100
Practice Address - Fax:210-579-9705
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37643103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3749426Medicaid
TX37643OtherTEXAS STATE PSYCHOLOGY LICENSE