Provider Demographics
NPI:1437223245
Name:WOOG, KENNETH MARK (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MARK
Last Name:WOOG
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22365 EL TORO RD
Mailing Address - Street 2:PMB 271
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-5053
Mailing Address - Country:US
Mailing Address - Phone:949-422-4120
Mailing Address - Fax:949-296-0398
Practice Address - Street 1:23591 EL TORO RD
Practice Address - Street 2:SUITE 104
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-4774
Practice Address - Country:US
Practice Address - Phone:949-422-4120
Practice Address - Fax:949-296-0398
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20560103TC2200X, 103TB0200X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily