Provider Demographics
NPI:1891211710
Name:VICENCIO, KENNETH (PSYD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:VICENCIO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10730 W 143RD ST STE 37
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-1940
Mailing Address - Country:US
Mailing Address - Phone:800-564-0863
Mailing Address - Fax:
Practice Address - Street 1:10730 W 143RD ST STE 37
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-1940
Practice Address - Country:US
Practice Address - Phone:800-564-0863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-22
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103G00000X
IL071009682103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist