Provider Demographics
NPI:1679832869
Name:CROSS, KENNETH L
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:CROSS
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 1:1812 SCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-2538
Mailing Address - Country:US
Mailing Address - Phone:213-663-3088
Mailing Address - Fax:
Practice Address - Street 1:1812 SCOTT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026
Practice Address - Country:US
Practice Address - Phone:213-663-3088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-09
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist