Provider Demographics
NPI:1205505302
Name:MALLON, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:MALLON
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 1:1210 S BASCOM AVE STE 114
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-3535
Mailing Address - Country:US
Mailing Address - Phone:650-487-0604
Mailing Address - Fax:
Practice Address - Street 1:950 S BASCOM AVE STE 2005
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-3538
Practice Address - Country:US
Practice Address - Phone:650-487-0604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-10
Last Update Date:2023-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA116516101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health