Provider Demographics
NPI:1104239821
Name:OXLEY, KENNETH D (PSYD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:D
Last Name:OXLEY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1680
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25717-1680
Mailing Address - Country:US
Mailing Address - Phone:304-697-1396
Mailing Address - Fax:304-697-2086
Practice Address - Street 1:3729 TEAYS VALLEY RD STE 100
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9705
Practice Address - Country:US
Practice Address - Phone:304-760-6040
Practice Address - Fax:304-760-6042
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1105103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810027771Medicaid
KY7100309300Medicaid
OH0106531Medicaid
WVQ49019AMedicare PIN
WVQ49019BMedicare PIN
WVC49019C197Medicare PIN
WV3810027771Medicaid