Provider Demographics
NPI:1720066376
Name:VICTOR, KENNETH J (PSY D)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:VICTOR
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6541 SPECKER AVE BLDG 1830
Mailing Address - Street 2:
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4263
Mailing Address - Country:US
Mailing Address - Phone:719-526-7155
Mailing Address - Fax:
Practice Address - Street 1:6541 SPECKER AVE BLDG 1830
Practice Address - Street 2:
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4263
Practice Address - Country:US
Practice Address - Phone:791-526-7155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041162A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200165440Medicaid
INP00196681OtherRR
ILP00453703OtherRR MEDICARE
ILK49099Medicare PIN
IN607350EMedicare ID - Type Unspecified
INP00196681OtherRR
ILP00453703OtherRR MEDICARE