Provider Demographics
NPI:1871679787
Name:MOCHIZUKI, KEVIN SCOTT (PHD DABNM)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:SCOTT
Last Name:MOCHIZUKI
Suffix:
Gender:M
Credentials:PHD DABNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 S DOUGLAS ST APT 1
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-3231
Mailing Address - Country:US
Mailing Address - Phone:435-414-0128
Mailing Address - Fax:951-742-4609
Practice Address - Street 1:428 S DOUGLAS ST APT 1
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102
Practice Address - Country:US
Practice Address - Phone:435-414-0128
Practice Address - Fax:951-742-4609
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4971390-41012084N0600X, 231H00000X
CAAU22312084N0600X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1871679787Medicaid
IN300015765Medicaid
MN1871679787Medicaid