Provider Demographics
NPI:1831673862
Name:KIKUCHI, KENNETH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:KIKUCHI
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:DR
Other - First Name:KEN
Other - Middle Name:
Other - Last Name:KIKUCHI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:4828 FARGO AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-3345
Mailing Address - Country:US
Mailing Address - Phone:872-228-5326
Mailing Address - Fax:
Practice Address - Street 1:111 S WASHINGTON AVE STE 202
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-4293
Practice Address - Country:US
Practice Address - Phone:872-228-5326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-14
Last Update Date:2023-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009712103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical