Provider Demographics
NPI:1497956346
Name:MANNING, KENNETH DAVID (PHD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:DAVID
Last Name:MANNING
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 1:112 POWERS RD
Mailing Address - Street 2:
Mailing Address - City:SUDBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01776-1028
Mailing Address - Country:US
Mailing Address - Phone:978-440-9123
Mailing Address - Fax:253-648-9123
Practice Address - Street 1:112 POWERS RD
Practice Address - Street 2:
Practice Address - City:SUDBURY
Practice Address - State:MA
Practice Address - Zip Code:01776-1028
Practice Address - Country:US
Practice Address - Phone:978-440-9123
Practice Address - Fax:253-648-9123
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6452103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist