Provider Demographics
NPI:1043464985
Name:NOGUCHI, KENTARO (MA)
Entity Type:Individual
Prefix:
First Name:KENTARO
Middle Name:
Last Name:NOGUCHI
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5694 MISSION CENTER RD STE 602-892
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4355
Mailing Address - Country:US
Mailing Address - Phone:619-909-7639
Mailing Address - Fax:619-297-4496
Practice Address - Street 1:5694 MISSION CENTER RD STE 602-892
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4355
Practice Address - Country:US
Practice Address - Phone:619-909-7639
Practice Address - Fax:619-297-4496
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF84509106H00000X
CA92408106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW416Medicare PIN