Provider Demographics
NPI:1477576114
Name:KRIPPNER, KEVIN M (PHD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:KRIPPNER
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 1:403 W VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3666
Mailing Address - Country:US
Mailing Address - Phone:309-268-5547
Mailing Address - Fax:309-268-2913
Practice Address - Street 1:403 W VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3666
Practice Address - Country:US
Practice Address - Phone:309-268-5547
Practice Address - Fax:309-268-2913
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004205101YA0400X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
05732028OtherBLUE CROSS BLUE SHIELD
05732028OtherBLUE CROSS BLUE SHIELD
S68003Medicare UPIN
L93583Medicare ID - Type Unspecified