Provider Demographics
NPI:1083774780
Name:BLANK, KENNETH ALLEN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ALLEN
Last Name:BLANK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 WOODBURY RD
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-4729
Mailing Address - Country:US
Mailing Address - Phone:631-385-1358
Mailing Address - Fax:
Practice Address - Street 1:755 NEW YORK AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-4240
Practice Address - Country:US
Practice Address - Phone:631-385-1358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013740103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01938045Medicaid
NYVJ4301Medicare ID - Type Unspecified