Provider Demographics
NPI:1700062528
Name:PROMENCHENKEL, KATHY L
Entity Type:Individual
Prefix:MS
First Name:KATHY
Middle Name:L
Last Name:PROMENCHENKEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7885 ANNANDALE AVE
Mailing Address - Street 2:
Mailing Address - City:DESERT HOT SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92240-1419
Mailing Address - Country:US
Mailing Address - Phone:760-329-2924
Mailing Address - Fax:
Practice Address - Street 1:58945 BUSINESS CENTER DR STE J
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-7310
Practice Address - Country:US
Practice Address - Phone:760-369-1074
Practice Address - Fax:760-418-8271
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
CA1406101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator