Provider Demographics
NPI:1942209127
Name:KENNEL, RICHARD G (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:G
Last Name:KENNEL
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 1:2901 OHIO BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803-2239
Mailing Address - Country:US
Mailing Address - Phone:812-232-2144
Mailing Address - Fax:812-234-4598
Practice Address - Street 1:2901 OHIO BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47803-2239
Practice Address - Country:US
Practice Address - Phone:812-232-2144
Practice Address - Fax:812-234-4598
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL20041262A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200192280Medicaid
IN200192280Medicaid
INS59367Medicare UPIN