Healthcare Provider Details

I. General information

NPI: 1083663835
Provider Name (Legal Business Name): KEVIN MICHAEL PERNICANO PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8800 VILLAGE DRIVE STE 209
SAN ANTONIO TX
78217
US

IV. Provider business mailing address

2071 WIND CHIME WAY
NEW BRAUNFELS TX
78130
US

V. Phone/Fax

Practice location:
  • Phone: 210-202-0100
  • Fax: 210-579-9705
Mailing address:
  • Phone: 210-278-4584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number37643
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: