Provider Demographics
NPI:1790709335
Name:SUBOTNIK, KENNETH L (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:SUBOTNIK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 UCLA MEDICAL PLZ
Mailing Address - Street 2:ROOM 2240
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-8346
Mailing Address - Country:US
Mailing Address - Phone:310-824-4600
Mailing Address - Fax:
Practice Address - Street 1:10850 WILSHIRE BLVD
Practice Address - Street 2:SUITE 240
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-4305
Practice Address - Country:US
Practice Address - Phone:310-824-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12770103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY127700Medicaid
CAR86258Medicare UPIN
CAPSY127700Medicaid