Provider Demographics
NPI:1558408690
Name:MEAGHER, KENNY (MFTI)
Entity Type:Individual
Prefix:
First Name:KENNY
Middle Name:
Last Name:MEAGHER
Suffix:
Gender:M
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2476 BALMORAL ST
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-1864
Mailing Address - Country:US
Mailing Address - Phone:510-441-8824
Mailing Address - Fax:
Practice Address - Street 1:39217 LIBERTY ST
Practice Address - Street 2:SUITE B 10
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1501
Practice Address - Country:US
Practice Address - Phone:510-791-3322
Practice Address - Fax:510-791-3325
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFTI 48558106H00000X
CAIMF48558101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YM0800XOtherMENTAL HEALTH