Provider Demographics
NPI:1689684029
Name:THUNBERG, KENNETH C (PH D)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:C
Last Name:THUNBERG
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7272 WURZBACH RD
Mailing Address - Street 2:SUITE 601
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-4801
Mailing Address - Country:US
Mailing Address - Phone:210-615-8880
Mailing Address - Fax:210-615-2279
Practice Address - Street 1:70 S WINOOSKI AVE
Practice Address - Street 2:SUITE 288
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-3898
Practice Address - Country:US
Practice Address - Phone:802-651-9700
Practice Address - Fax:210-615-2279
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT048-0000875103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN3913Medicaid
VTVN3913Medicare ID - Type UnspecifiedVT DOMHA