Healthcare Provider Details

I. General information

NPI: 1609245042
Provider Name (Legal Business Name): MICHAEL KENNY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5842 ROSSLYN AVE
INDIANAPOLIS IN
46220-2777
US

IV. Provider business mailing address

5842 ROSSLYN AVE
INDIANAPOLIS IN
46220-2777
US

V. Phone/Fax

Practice location:
  • Phone: 317-864-9052
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number20441837A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: