Provider Demographics
NPI:1770697336
Name:CARRICO, JR., KENNETH LEE JR (PHD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEE
Last Name:CARRICO, JR.
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:3050 11TH AVENUE DR SE
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602-8336
Mailing Address - Country:US
Mailing Address - Phone:828-695-5900
Mailing Address - Fax:828-695-4256
Practice Address - Street 1:1001 E UNION ST STE B
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-2863
Practice Address - Country:US
Practice Address - Phone:828-438-6226
Practice Address - Fax:828-438-6225
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP00956103TC0700X
NC3289103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000931Medicaid