Provider Demographics
NPI:1942238266
Name:DE LUCA, KENNETH ANTHONY (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ANTHONY
Last Name:DE LUCA
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 1:35888 CENTER RIDGE RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:NORTH RIDGEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44039-3086
Mailing Address - Country:US
Mailing Address - Phone:440-327-1800
Mailing Address - Fax:440-327-1533
Practice Address - Street 1:35888 CENTER RIDGE RD
Practice Address - Street 2:SUITE 5
Practice Address - City:NORTH RIDGEVILLE
Practice Address - State:OH
Practice Address - Zip Code:44039-3086
Practice Address - Country:US
Practice Address - Phone:440-327-1800
Practice Address - Fax:440-327-1533
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2076103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCP04182Medicare ID - Type Unspecified
OH228960Medicare UPIN