Provider Demographics
NPI:1497882302
Name:KAWAGOE, KENT M (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:M
Last Name:KAWAGOE
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 1:5740 N PALM AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704-1800
Mailing Address - Country:US
Mailing Address - Phone:559-431-1900
Mailing Address - Fax:559-431-1951
Practice Address - Street 1:5740 N PALM AVE STE 105
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93704-1800
Practice Address - Country:US
Practice Address - Phone:559-431-1900
Practice Address - Fax:559-431-1951
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13709103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL137091Medicare ID - Type Unspecified