Healthcare Provider Details

I. General information

NPI: 1306801410
Provider Name (Legal Business Name): KENNETH P KUSHNER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 DANE STREET
MADISON WI
53713
US

IV. Provider business mailing address

6714 COLONY DR
MADISON WI
53717-1125
US

V. Phone/Fax

Practice location:
  • Phone: 608-263-3111
  • Fax: 608-263-6663
Mailing address:
  • Phone: 608-833-8586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number923
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: