Provider Demographics
NPI:1023655875
Name:CINNAMON, KENNETH MARK (PHD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:MARK
Last Name:CINNAMON
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 1:4021 STONEYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-4549
Mailing Address - Country:US
Mailing Address - Phone:818-929-8204
Mailing Address - Fax:
Practice Address - Street 1:4021 STONEYBROOK DR
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-4549
Practice Address - Country:US
Practice Address - Phone:818-929-8204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20890103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist