Provider Demographics
NPI:1477741056
Name:KENNY, MICHAEL PHILLIP (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PHILLIP
Last Name:KENNY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 INTERNATIONAL CIR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3139
Mailing Address - Country:US
Mailing Address - Phone:719-238-3010
Mailing Address - Fax:
Practice Address - Street 1:2350 INTERNATIONAL CIR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3139
Practice Address - Country:US
Practice Address - Phone:719-238-3010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1626103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COR-18880Medicare UPIN