Provider Demographics
NPI:1295361731
Name:MUNOZ-PORTER, KENNETH ALLEN
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:ALLEN
Last Name:MUNOZ-PORTER
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 1:1171 E ALOSTA AVE # 342
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-2740
Mailing Address - Country:US
Mailing Address - Phone:626-802-7699
Mailing Address - Fax:626-415-6770
Practice Address - Street 1:1171 E ALOSTA AVE # 342
Practice Address - Street 2:
Practice Address - City:AZUSA
Practice Address - State:CA
Practice Address - Zip Code:91702-2740
Practice Address - Country:US
Practice Address - Phone:626-802-7699
Practice Address - Fax:626-415-6770
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-17
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X, 171M00000X, 246Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Y00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Health Information
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator