Provider Demographics
NPI:1912315987
Name:CARPENTER, KENNETH BRADFORD (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:BRADFORD
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 BLUE RIDGE OVERLOOK
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-4431
Mailing Address - Country:US
Mailing Address - Phone:706-946-5607
Mailing Address - Fax:706-374-7628
Practice Address - Street 1:165 BLUE RIDGE OVERLOOK
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-4431
Practice Address - Country:US
Practice Address - Phone:706-946-4647
Practice Address - Fax:706-374-5006
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003825103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003151473CMedicaid
GA003151473DMedicaid