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NPI Code Detail

MEDICARE: DR. KENNETH ALLEN DEHERRERA PH.D.

MEDICARE: DR. KENNETH ALLEN DEHERRERA PH.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103T00000XPsychologist263423-2501UT

General Provider Information

NPI Number : 1255386769
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. KENNETH ALLEN DEHERRERA PH.D.
Provider Business Mailing Address
First Line : 410 HOLCOMB ST
Second Line :
City : WATERTOWN
State : NY
Zip : 13601-3907
Country : US
Telephone Number : 801-450-4414
Fax Number :
Provider Business Practice Location Address
First Line : DEPARTMENT OF THE ARMY, U.S. ARMY MEDICAL DEPARTMENT
Second Line : ACTIVITY, FORT DRUM, NEW YORK
City : WATERETOWN
State : NY
Zip : 13602-5004
Country : US
Telephone Number : 315-772-3314
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/23/2006
Last Update Date : 07/08/2007

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