MEDICARE: KENNETH J VICTOR PSY. D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	20041162A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00453703	OTHER	IL	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	P00196681	OTHER	IN	RR

General Provider Information

NPI Number	:	1720066376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH J VICTOR PSY. D.

Provider Business Mailing Address
First Line	:	6541 SPECKER AVE BLDG 1830
Second Line	:
City	:	FORT CARSON
State	:	CO
Zip	:	80913-4263
Country	:	US
Telephone Number	:	719-526-7155
Fax Number	:

Provider Business Practice Location Address
First Line	:	6541 SPECKER AVE BLDG 1830
Second Line	:
City	:	FORT CARSON
State	:	CO
Zip	:	80913-4263
Country	:	US
Telephone Number	:	791-526-7155
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2006
Last Update Date	:	11/28/2023

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