Provider Demographics
NPI:1306818653
Name:KAISER, KENNETH JOSEPH (LCSW)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOSEPH
Last Name:KAISER
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 1:12420 BAKER AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-2303
Mailing Address - Country:US
Mailing Address - Phone:909-702-2068
Mailing Address - Fax:
Practice Address - Street 1:585 N MOUNTAIN AVE STE B
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-8516
Practice Address - Country:US
Practice Address - Phone:909-702-2068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS133581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACSW133580Medicaid
CAEPS011090Medicaid
CACB 231908Medicare UPIN
CAEPS011090Medicaid
CAB 1205ZMedicare UPIN