Healthcare Provider Details

I. General information

NPI: 1275971665
Provider Name (Legal Business Name): KENNETH JOHN CARR PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2013
Last Update Date: 06/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

641 N FOWLER AVE APT #255
CLOVIS CA
93611-6610
US

IV. Provider business mailing address

641 N FOWLER AVE APT #255
CLOVIS CA
93611-6610
US

V. Phone/Fax

Practice location:
  • Phone: 209-201-2299
  • Fax:
Mailing address:
  • Phone: 209-201-2299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0000000000
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number00000000000
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: