Basic Information
Provider Information | |||||||||
NPI: | 1861475212 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HARRY KENT PHD PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3540 N SOUTHPORT | ||||||||
Address2: | #272 | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 60657 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7733982415 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 77 N AIRLITE STREET | ||||||||
Address2: | PROVENA ST JOSEPH HOSPITAL | ||||||||
City: | ELGIN | ||||||||
State: | IL | ||||||||
PostalCode: | 601234912 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8476953200 | ||||||||
FaxNumber: | 9476223470 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/21/2005 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KENT | ||||||||
AuthorizedOfficialFirstName: | HARRY | ||||||||
AuthorizedOfficialMiddleName: | MASON | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7733982415 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X |   | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
ID | Type | State | Issuer | Description | 04532067 | 01 |   | BCBS | OTHER |