Provider Demographics
NPI:1043761448
Name:WANG, KENNETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:WANG
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 1:180 N OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1714
Mailing Address - Country:US
Mailing Address - Phone:626-304-3712
Mailing Address - Fax:
Practice Address - Street 1:180 N OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1714
Practice Address - Country:US
Practice Address - Phone:626-304-3712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27680103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist