Provider Demographics
NPI:1225076888
Name:VISSER, KENNETH A (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:VISSER
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 1:2246 CIRCLEWOOD DR.
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-5741
Mailing Address - Country:US
Mailing Address - Phone:941-927-4797
Mailing Address - Fax:941-927-4797
Practice Address - Street 1:1720 EL JOBEAN RD.
Practice Address - Street 2:SUITE 111
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-1286
Practice Address - Country:US
Practice Address - Phone:941-927-4797
Practice Address - Fax:941-927-4797
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2667103T00000X
FLPY0002667103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist