Basic Information
| Provider Information | |||||||||
| NPI: | 1689684029 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THUNBERG | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PH D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7272 WURZBACH RD | ||||||||
| Address2: | SUITE 601 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782404801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106158880 | ||||||||
| FaxNumber: | 2106152279 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 S WINOOSKI AVE | ||||||||
| Address2: | SUITE 288 | ||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054013898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8026519700 | ||||||||
| FaxNumber: | 2106152279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 02/26/2008 | ||||||||
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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 | 103TC0700X | 048-0000875 | VT | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0VN3913 | 05 | VT | MEDICAID |