Provider Demographics
NPI:1023764057
Name:BUFORD, KENYATTA
Entity type:Individual
Prefix:
First Name:KENYATTA
Middle Name:
Last Name:BUFORD
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 1:825 E MOBECK ST APT A
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-6708
Mailing Address - Country:US
Mailing Address - Phone:626-549-9970
Mailing Address - Fax:
Practice Address - Street 1:2243 N MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-1586
Practice Address - Country:US
Practice Address - Phone:909-371-6830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-28
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW106197101YM0800X, 1041C0700X
CAA1061971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health