Provider Demographics
NPI:1235240367
Name:KINGAN, PETER LYNN (PHD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:LYNN
Last Name:KINGAN
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 1:31 OAK ST
Mailing Address - Street 2:21
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-2887
Mailing Address - Country:US
Mailing Address - Phone:631-447-6425
Mailing Address - Fax:631-776-8027
Practice Address - Street 1:31 OAK ST
Practice Address - Street 2:21
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-2887
Practice Address - Country:US
Practice Address - Phone:631-447-6425
Practice Address - Fax:631-776-8027
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0011037103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYY042249OtherCHAMPUS/CHAMPVA
NY01386290Medicaid
NYV1C011Medicare ID - Type Unspecified
NY01386290Medicaid