Provider Demographics
NPI:1053460733
Name:DEAVER, KENNETH J (LCSW)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:DEAVER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15951 LOS GATOS BLVD STE 18
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-3488
Mailing Address - Country:US
Mailing Address - Phone:408-358-9596
Mailing Address - Fax:408-358-9596
Practice Address - Street 1:15951 LOS GATOS BLVD STE 18
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-3488
Practice Address - Country:US
Practice Address - Phone:408-358-9596
Practice Address - Fax:408-358-9596
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS165851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical