Provider Demographics
NPI:1477251288
Name:CORREA, KENNETH ALEXIS I
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ALEXIS
Last Name:CORREA
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:PO BOX 1570
Mailing Address - Street 2:
Mailing Address - City:BARCELONETA
Mailing Address - State:PR
Mailing Address - Zip Code:00617-1570
Mailing Address - Country:US
Mailing Address - Phone:787-970-4634
Mailing Address - Fax:
Practice Address - Street 1:CDT CESAR ROSA FEBLES EDIFICIO ANEJO PISO2 SR 2, KM 50,
Practice Address - Street 2:
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00617
Practice Address - Country:US
Practice Address - Phone:787-641-9133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR163541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR16354OtherAPS