Provider Demographics
NPI:1992395693
Name:DONAHUE, KENNETH SCOTT
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:SCOTT
Last Name:DONAHUE
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 1:1031 LA PRESA AVE
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-4415
Mailing Address - Country:US
Mailing Address - Phone:619-408-0846
Mailing Address - Fax:
Practice Address - Street 1:2049 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:LEMON GROVE
Practice Address - State:CA
Practice Address - Zip Code:91945-4221
Practice Address - Country:US
Practice Address - Phone:619-465-7303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility