Provider Demographics
NPI:1598924953
Name:KENNETH SUBOTNIK, PH.D., INC
Entity Type:Organization
Organization Name:KENNETH SUBOTNIK, PH.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SUBOTNIK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:310-824-4600
Mailing Address - Street 1:10850 WILSHIRE BLVD STE 240
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-4308
Mailing Address - Country:US
Mailing Address - Phone:310-824-4600
Mailing Address - Fax:
Practice Address - Street 1:10850 WILSHIRE BLVD STE 240
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-4308
Practice Address - Country:US
Practice Address - Phone:310-824-4600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12770261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY127700Medicaid
CAPSY12770OtherCALIFORNIA PSYCHOLOGIST LICENSE
CAPSY127700Medicaid
CACP12770Medicare PIN