Provider Demographics
NPI:1770637100
Name:MICHAELS, KENNETH WILLIAM (MSED)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:WILLIAM
Last Name:MICHAELS
Suffix:
Gender:M
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:832 MCKENZIE STREET
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17403-3122
Mailing Address - Country:US
Mailing Address - Phone:717-845-2242
Mailing Address - Fax:717-854-0000
Practice Address - Street 1:220 EAST KING STREET
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:VA
Practice Address - Zip Code:17403
Practice Address - Country:US
Practice Address - Phone:717-843-4357
Practice Address - Fax:717-854-0000
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPA003003L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1009022770001Medicare ID - Type Unspecified