Healthcare Provider Details

I. General information

NPI: 1235240367
Provider Name (Legal Business Name): PETER LYNN KINGAN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

31 OAK ST 21
PATCHOGUE NY
11772-2887
US

IV. Provider business mailing address

31 OAK ST 21
PATCHOGUE NY
11772-2887
US

V. Phone/Fax

Practice location:
  • Phone: 631-447-6425
  • Fax: 631-776-8027
Mailing address:
  • Phone: 631-447-6425
  • Fax: 631-776-8027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number0011037
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierY042249
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerCHAMPUS/CHAMPVA
# 2
Identifier01386290
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: