Provider Demographics
NPI:1245413590
Name:MOORE, KENNETH
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:MOORE
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 1:600 HOSKING AVE APT 71A
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93307-5739
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3628 STOCKDALE HWY
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-2153
Practice Address - Country:US
Practice Address - Phone:661-322-1021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54835101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health