Provider Demographics
NPI:1457317943
Name:KENNY, PETER (PHD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
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:N91W17271 APPLETON AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-2045
Mailing Address - Country:US
Mailing Address - Phone:262-502-3300
Mailing Address - Fax:
Practice Address - Street 1:N91W17271 APPLETON AVE STE 1
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-2045
Practice Address - Country:US
Practice Address - Phone:262-502-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1036103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39186700Medicaid
WI0218Medicare ID - Type Unspecified
WI68375Medicare PIN
WI39186700Medicaid
WIR79416Medicare UPIN