Provider Demographics
NPI:1114368495
Name:KENNY, GAVIN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GAVIN
Middle Name:
Last Name:KENNY
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 1:726 BROADWAY
Mailing Address - Street 2:SUITE 471
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-9502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:726 BROADWAY
Practice Address - Street 2:SUITE 471
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-9502
Practice Address - Country:US
Practice Address - Phone:212-443-1365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-15
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020162103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical