Provider Demographics
NPI:1689744005
Name:KANG, EILEEN SWAN (PHD)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:SWAN
Last Name:KANG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 54842
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92619
Mailing Address - Country:US
Mailing Address - Phone:949-556-9190
Mailing Address - Fax:949-556-9190
Practice Address - Street 1:6 VENTURE SUITE 350
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-1040
Practice Address - Country:US
Practice Address - Phone:949-556-9190
Practice Address - Fax:949-556-9190
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20310103G00000X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWCP20310AMedicare PIN
CAQ62020Medicare UPIN