Provider Demographics
NPI:1700390366
Name:SPEARS, KENNETH BERNARD (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:BERNARD
Last Name:SPEARS
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 1:6507 PACIFIC AVE # 194
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-3717
Mailing Address - Country:US
Mailing Address - Phone:323-481-9681
Mailing Address - Fax:
Practice Address - Street 1:1644 OXFORD WAY
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-4259
Practice Address - Country:US
Practice Address - Phone:323-481-9681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-18
Last Update Date:2017-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29427103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical