Provider Demographics
NPI:1407844277
Name:KENT, PHILLIP L (PSYD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:L
Last Name:KENT
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 1:865 LINCOLN RD
Mailing Address - Street 2:STE L10
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-4190
Mailing Address - Country:US
Mailing Address - Phone:563-355-9191
Mailing Address - Fax:563-355-3419
Practice Address - Street 1:4455 E 56TH ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2995
Practice Address - Country:US
Practice Address - Phone:563-355-2577
Practice Address - Fax:563-355-4015
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00929103G00000X, 103T00000X
IA00424103T00000X
MNLP1079103T00000X
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0447185Medicaid
IA45245OtherWELLMARK HEALTH PLAN
IA01C3OtherJOHN DEERE HEALTH PLAN
IA45245OtherWELLMARK HEALTH PLAN
IAI7149Medicare ID - Type UnspecifiedMEDICARE NUMBER