Provider Demographics
NPI:1275971665
Name:CARR, KENNETH JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JOHN
Last Name:CARR
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 1:641 N FOWLER AVE
Mailing Address - Street 2:APT #255
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-6610
Mailing Address - Country:US
Mailing Address - Phone:209-201-2299
Mailing Address - Fax:
Practice Address - Street 1:641 N FOWLER AVE
Practice Address - Street 2:APT #255
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6610
Practice Address - Country:US
Practice Address - Phone:209-201-2299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0000000000103TC0700X
CA00000000000103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic