Healthcare Provider Details

I. General information

NPI: 1437165685
Provider Name (Legal Business Name): SEAN J KENNY PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 FULTON ST E SUITE 428
GRAND RAPIDS MI
49503-3200
US

IV. Provider business mailing address

233 FULTON ST E SUITE 428
GRAND RAPIDS MI
49503-3200
US

V. Phone/Fax

Practice location:
  • Phone: 616-752-8381
  • Fax:
Mailing address:
  • Phone: 616-752-8381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301009458
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: