Provider Demographics
NPI:1649616087
Name:SEKULIC, KENNETH DAVID (PSYD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:DAVID
Last Name:SEKULIC
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9388 BABAUTA RD
Mailing Address - Street 2:SUITE 128
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-4932
Mailing Address - Country:US
Mailing Address - Phone:619-556-7641
Mailing Address - Fax:619-556-8413
Practice Address - Street 1:3075 CORBINA ALY
Practice Address - Street 2:SUITE 1
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92136-5112
Practice Address - Country:US
Practice Address - Phone:619-556-7641
Practice Address - Fax:619-556-8413
Is Sole Proprietor?:No
Enumeration Date:2013-05-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016339103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical