Provider Demographics
NPI:1104879394
Name:MANGES, KENNETH J (PHD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:MANGES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:810 SYCAMORE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-2156
Mailing Address - Country:US
Mailing Address - Phone:513-784-1333
Mailing Address - Fax:513-338-1920
Practice Address - Street 1:810 SYCAMORE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45202-2156
Practice Address - Country:US
Practice Address - Phone:513-784-1333
Practice Address - Fax:513-338-1920
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3656103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0638859Medicaid
OH0638859Medicaid