Provider Demographics
NPI:1962626317
Name:BERNEY, KENT M (PHD)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:M
Last Name:BERNEY
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 1:520 UNIVERSITY AVE
Mailing Address - Street 2:SUITE # 300
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-4915
Mailing Address - Country:US
Mailing Address - Phone:608-255-3340
Mailing Address - Fax:
Practice Address - Street 1:1300 SOUTH DRIVE
Practice Address - Street 2:
Practice Address - City:WINNEBAGO
Practice Address - State:WI
Practice Address - Zip Code:54985-0009
Practice Address - Country:US
Practice Address - Phone:920-235-4910
Practice Address - Fax:920-236-2931
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2008-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1266-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1266-057OtherLICENSE