Provider Demographics
NPI:1467178897
Name:CARRERA, KENNY R I
Entity Type:Individual
Prefix:
First Name:KENNY
Middle Name:R
Last Name:CARRERA
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N 38TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-7616
Mailing Address - Country:US
Mailing Address - Phone:703-655-9600
Mailing Address - Fax:
Practice Address - Street 1:2601 WILLARD RD STE 105
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23294-3638
Practice Address - Country:US
Practice Address - Phone:804-261-0696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-18
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician