Basic Information
| Provider Information | |||||||||
| NPI: | 1407844277 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENT | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 865 LINCOLN RD | ||||||||
| Address2: | STE L10 | ||||||||
| City: | BETTENDORF | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527224190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633559191 | ||||||||
| FaxNumber: | 5633553419 | ||||||||
| Practice Location | |||||||||
| Address1: | 4455 E 56TH ST | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528072995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633552577 | ||||||||
| FaxNumber: | 5633554015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 00929 | IA | X | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103T00000X | 00424 | IA | X | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | 00929 | IA | X | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | LP1079 | MN | X | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | IL | X | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 0447185 | 05 | IA | MEDICAID | 45245 | 01 | IA | WELLMARK HEALTH PLAN | OTHER | IA01C3 | 01 | JOHN DEERE HEALTH PLAN | OTHER |