Provider Demographics
NPI:1629109236
Name:TABLADA, KENT B (EDD; LMFT)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:B
Last Name:TABLADA
Suffix:
Gender:M
Credentials:EDD; LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13015 LULL ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91605-1925
Mailing Address - Country:US
Mailing Address - Phone:818-764-7860
Mailing Address - Fax:818-764-3458
Practice Address - Street 1:427 ENCINAL CANYON RD
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-2404
Practice Address - Country:US
Practice Address - Phone:818-735-2870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT48722106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist