Provider Demographics
NPI:1760564447
Name:WOLKON, KENNETH A (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:WOLKON
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 1:89 ACCESS RD
Mailing Address - Street 2:SUITE 24
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-5229
Mailing Address - Country:US
Mailing Address - Phone:781-551-0999
Mailing Address - Fax:781-551-3396
Practice Address - Street 1:89 ACCESS RD
Practice Address - Street 2:SUITE 24
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-5229
Practice Address - Country:US
Practice Address - Phone:781-551-0999
Practice Address - Fax:781-551-3396
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA312103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA30257-1OtherBCBS/RI
MA709359OtherTUFTS
MAR43635OtherMAGELLAN
MA000960OtherVALUE OPTIONS
MA042659047OtherPACIFICARE
MA042659047OtherTEAMSTERS
MAW01643OtherBCBS
MAW01643Medicare ID - Type Unspecified