Provider Demographics
NPI:1578629390
Name:PHILIPP, KENNETH RAY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RAY
Last Name:PHILIPP
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1891 E ROSEVILLE PKWY
Mailing Address - Street 2:STE 100
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661
Mailing Address - Country:US
Mailing Address - Phone:916-789-7082
Mailing Address - Fax:916-797-8840
Practice Address - Street 1:1891 E ROSEVILLE PKWY
Practice Address - Street 2:STE 100
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661
Practice Address - Country:US
Practice Address - Phone:916-789-7082
Practice Address - Fax:916-797-8840
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17630103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist