Provider Demographics
NPI:1992749709
Name:HERSHBERGER, KENT A (HSPP)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:A
Last Name:HERSHBERGER
Suffix:
Gender:M
Credentials:HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 W ANGELA BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1101
Mailing Address - Country:US
Mailing Address - Phone:574-220-4968
Mailing Address - Fax:
Practice Address - Street 1:150 W ANGELA BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-1101
Practice Address - Country:US
Practice Address - Phone:574-220-4968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041322A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200264420Medicaid
IN000000202186OtherANTHEM
IN200288970Medicaid
IN200288970Medicaid