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General NPI Number Information
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NPI Number | 1225076888
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Entity Type | Individual
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Provider Name | KENNETH A VISSER PH.D.
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Gender | Male
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Dates
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Enumeration Date | 06/03/2006
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Last Update Date | 06/20/2012
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Provider Practice Location Address
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Address Line | 1720 EL JOBEAN RD. SUITE 111
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City | PORT CHARLOTTE
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State | FL
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Zip | 33948-1286
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Country | US
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Telephone | 941-927-4797
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Fax | 941-927-4797
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Provider Business Mailing Address
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Address Line | 2246 CIRCLEWOOD DR.
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City | SARASOTA
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State | FL
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Zip | 34231-5741
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Country | US
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Telephone | 941-927-4797
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Fax | 941-927-4797
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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 | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PY2667
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PY0002667
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License Number State | FL
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