Provider Demographics
NPI:1154511673
Name:ANGELO, KEN (MFT)
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:ANGELO
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5429
Mailing Address - Country:US
Mailing Address - Phone:510-501-9725
Mailing Address - Fax:
Practice Address - Street 1:516 OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5429
Practice Address - Country:US
Practice Address - Phone:510-501-9725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40896106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01674804Medicare PIN