Provider Demographics
NPI:1255386769
Name:DEHERRERA, KENNETH ALLEN (PHD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ALLEN
Last Name:DEHERRERA
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 1:410 HOLCOMB ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3907
Mailing Address - Country:US
Mailing Address - Phone:801-450-4414
Mailing Address - Fax:
Practice Address - Street 1:DEPARTMENT OF THE ARMY, U.S. ARMY MEDICAL DEPARTMENT
Practice Address - Street 2:ACTIVITY, FORT DRUM, NEW YORK
Practice Address - City:WATERETOWN
Practice Address - State:NY
Practice Address - Zip Code:13602-5004
Practice Address - Country:US
Practice Address - Phone:315-772-3314
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT263423-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist