Provider Demographics
NPI:1659690071
Name:MEGINNES, KODY AYDON
Entity Type:Individual
Prefix:
First Name:KODY
Middle Name:AYDON
Last Name:MEGINNES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 BANCROFT RD
Mailing Address - Street 2:#430
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-1531
Mailing Address - Country:US
Mailing Address - Phone:707-709-4209
Mailing Address - Fax:
Practice Address - Street 1:1415 OAKLAND BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-4386
Practice Address - Country:US
Practice Address - Phone:707-709-4209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-25
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80883106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist