Provider Demographics
NPI:1053635706
Name:REAGON, KWAN
Entity Type:Individual
Prefix:
First Name:KWAN
Middle Name:
Last Name:REAGON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 WAYNE AVE APT D
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-1234
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6330 THORNTON AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-3734
Practice Address - Country:US
Practice Address - Phone:510-792-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)