Provider Demographics
NPI:1437165685
Name:KENNY, SEAN J (PHD)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:J
Last Name:KENNY
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 1:233 FULTON ST E
Mailing Address - Street 2:SUITE 428
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3200
Mailing Address - Country:US
Mailing Address - Phone:616-752-8381
Mailing Address - Fax:
Practice Address - Street 1:233 FULTON ST E
Practice Address - Street 2:SUITE 428
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3200
Practice Address - Country:US
Practice Address - Phone:616-752-8381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009458103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI68-0-D1-4643-0OtherBLUE CROSS PROVIDER ID
MI0P11590Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID