Provider Demographics
NPI:1609245042
Name:KENNY, MICHAEL (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KENNY
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 1:737 E 86TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-1803
Mailing Address - Country:US
Mailing Address - Phone:317-560-0718
Mailing Address - Fax:
Practice Address - Street 1:737 E 86TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1803
Practice Address - Country:US
Practice Address - Phone:317-560-0718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20441837A103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service