1083663835 NPI number — DR. KEVIN MICHAEL PERNICANO PHD

Table of content: DR. KEVIN MICHAEL PERNICANO PHD (NPI 1083663835)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083663835 NPI number — DR. KEVIN MICHAEL PERNICANO PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERNICANO
Provider First Name:
KEVIN
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083663835
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2071 WIND CHIME WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW BRAUNFELS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-278-4584
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8800 VILLAGE DRIVE
Provider Second Line Business Practice Location Address:
STE 209
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-202-0100
Provider Business Practice Location Address Fax Number:
210-579-9705
Provider Enumeration Date:
05/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  37643 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3749426 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 37643 . This is a "TEXAS STATE PSYCHOLOGY LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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