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General NPI Number Information
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NPI Number | 1083663835
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Entity Type | Individual
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Provider Name | KEVIN MICHAEL PERNICANO PHD
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Gender | Male
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Dates
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Enumeration Date | 05/09/2006
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Last Update Date | 03/16/2020
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Provider Practice Location Address
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Address Line | 8800 VILLAGE DRIVE STE 209
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City | SAN ANTONIO
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State | TX
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Zip | 78217
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Country | US
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Telephone | 210-202-0100
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Fax | 210-579-9705
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Provider Business Mailing Address
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Address Line | 2071 WIND CHIME WAY
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City | NEW BRAUNFELS
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State | TX
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Zip | 78130
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Country | US
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Telephone | 210-278-4584
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 37643
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License Number State | TX
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