Provider Demographics
NPI:1639280746
Name:BERTRAM, KENNY (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNY
Middle Name:
Last Name:BERTRAM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:KEN
Other - Middle Name:
Other - Last Name:BERTRAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1485 AVALON AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48638-4720
Mailing Address - Country:US
Mailing Address - Phone:989-598-5962
Mailing Address - Fax:
Practice Address - Street 1:3521 STATE ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-3267
Practice Address - Country:US
Practice Address - Phone:989-791-1740
Practice Address - Fax:989-791-1746
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005719103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical