Provider Demographics
NPI:1457331167
Name:ISRAEL, KENNETH JAMES (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JAMES
Last Name:ISRAEL
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 1:1040 GASKILL DR
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50014-7819
Mailing Address - Country:US
Mailing Address - Phone:515-269-4315
Mailing Address - Fax:
Practice Address - Street 1:3600 LINCOLN WAY
Practice Address - Street 2:SUITE 4
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50014-7595
Practice Address - Country:US
Practice Address - Phone:515-239-4410
Practice Address - Fax:515-663-4885
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00910103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA33401OtherBLUE SHIELD OF IOWA
IAS62246Medicare UPIN
IAI9077Medicare ID - Type Unspecified