Provider Demographics
NPI:1992398366
Name:CONLEY, KENSHASA TSHOMBE
Entity Type:Individual
Prefix:
First Name:KENSHASA
Middle Name:TSHOMBE
Last Name:CONLEY
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 1:3639 W 133RD ST
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-6217
Mailing Address - Country:US
Mailing Address - Phone:818-208-6677
Mailing Address - Fax:
Practice Address - Street 1:2122 W 107TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90047-4305
Practice Address - Country:US
Practice Address - Phone:323-696-9749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA118860106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist