Provider Demographics
NPI:1528287612
Name:PROSNICK, KEVIN (PHD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:PROSNICK
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 1:154 HOGAN LN NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-5545
Mailing Address - Country:US
Mailing Address - Phone:330-423-5066
Mailing Address - Fax:
Practice Address - Street 1:154 HOGAN LN NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-5545
Practice Address - Country:US
Practice Address - Phone:330-423-5066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5430103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2072680Medicaid
OHS57972Medicare UPIN
OHCP21363Medicare ID - Type Unspecified