Provider Demographics
NPI:1477562627
Name:NUNNELLY, KENNETH G (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:G
Last Name:NUNNELLY
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 1:1302 N ALDEN RD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-2903
Mailing Address - Country:US
Mailing Address - Phone:765-284-0751
Mailing Address - Fax:765-282-4899
Practice Address - Street 1:9292 N MERIDIAN ST
Practice Address - Street 2:SUITE 311
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1857
Practice Address - Country:US
Practice Address - Phone:317-592-9208
Practice Address - Fax:765-282-4899
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20090080A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist