Provider Demographics
NPI:1871527663
Name:LEIGHT, KENNETH A (PHD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:LEIGHT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 NEW ROAD
Mailing Address - Street 2:SUITE F3
Mailing Address - City:LINWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08221
Mailing Address - Country:US
Mailing Address - Phone:609-926-1165
Mailing Address - Fax:609-926-1228
Practice Address - Street 1:2106 NEW ROAD
Practice Address - Street 2:SUITE F3
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221
Practice Address - Country:US
Practice Address - Phone:609-926-1165
Practice Address - Fax:609-926-1228
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJSI00255900103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
621661Medicare ID - Type Unspecified
R32677Medicare UPIN