Provider Demographics
NPI:1699720649
Name:KUNKLE, KATHLEEN GAYLE (PHD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:GAYLE
Last Name:KUNKLE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:GAYLE
Other - Last Name:ISGRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:6978 RENIE RD
Mailing Address - Street 2:
Mailing Address - City:BELLVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44813-8908
Mailing Address - Country:US
Mailing Address - Phone:419-886-4565
Mailing Address - Fax:
Practice Address - Street 1:3591 RESERVE COMMONS DR
Practice Address - Street 2:SUITE 301
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-5334
Practice Address - Country:US
Practice Address - Phone:330-764-7916
Practice Address - Fax:330-723-6399
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5197103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist