Provider Demographics
NPI:1467586701
Name:KILBOURNE, BROCK KENNETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:BROCK
Middle Name:KENNETH
Last Name:KILBOURNE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29821 VALLE OLVERA ST
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-1638
Mailing Address - Country:US
Mailing Address - Phone:951-676-4949
Mailing Address - Fax:951-676-4949
Practice Address - Street 1:2181 S EL CAMINO REAL STE 307
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-6288
Practice Address - Country:US
Practice Address - Phone:760-722-4233
Practice Address - Fax:760-722-4232
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10467103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY10467Medicaid
CAPSY10467Medicaid