Provider Demographics
NPI:1720108111
Name:MCNIEL, KENNETH L (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:MCNIEL
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 1:128 SAINT PAUL ST
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07090-2145
Mailing Address - Country:US
Mailing Address - Phone:908-273-3465
Mailing Address - Fax:
Practice Address - Street 1:128 SAINT PAUL ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-2145
Practice Address - Country:US
Practice Address - Phone:908-273-3465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2749103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ659325Medicare ID - Type Unspecified