Basic Information
Provider Information | |||||||||
NPI: | 1679532014 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LERNER | ||||||||
FirstName: | KENNETH | ||||||||
MiddleName: | G. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 445 CYPRESS STREET | ||||||||
Address2: | MANCHESTER COUNSELING SERVICES, SUITE 8 | ||||||||
City: | MANCHESTER | ||||||||
State: | NH | ||||||||
PostalCode: | 03103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6036684079 | ||||||||
FaxNumber: | 6036638605 | ||||||||
Practice Location | |||||||||
Address1: | 445 CYPRESS STREET, | ||||||||
Address2: | MANCHESTER COUNSELING SERVICES SUITE 8 | ||||||||
City: | MANCHESTER | ||||||||
State: | NH | ||||||||
PostalCode: | 03103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6036684079 | ||||||||
FaxNumber: | 6036638605 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/23/2006 | ||||||||
LastUpdateDate: | 07/12/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | 10953 | NH | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 794910 | 01 | NH | MVP PIN | OTHER | 01Y007645NH01 | 01 | NH | ANTHEM ACES # | OTHER | 2102931 | 01 | NH | CIGNA BH PIN | OTHER | 30201544 | 05 | NH |   | MEDICAID |