Provider Demographics
NPI:1093838823
Name:MEYER, KENNETH (PHD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:MEYER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:554 LAKES RD
Mailing Address - Street 2:WALTON LAKE
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-1070
Mailing Address - Country:US
Mailing Address - Phone:516-909-8725
Mailing Address - Fax:
Practice Address - Street 1:31 W 9TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-9206
Practice Address - Country:US
Practice Address - Phone:516-909-8725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-08
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004485103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY138123OtherVALUE OPTIONS