Provider Demographics
NPI:1720097983
Name:KILBANE, KEVIN MICHAEL (PH D, MA, MFT)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:KILBANE
Suffix:
Gender:M
Credentials:PH D, MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3815 ATLANTIC AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-3500
Mailing Address - Country:US
Mailing Address - Phone:562-424-8503
Mailing Address - Fax:562-424-8772
Practice Address - Street 1:3815 ATLANTIC AVE STE 2
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3500
Practice Address - Country:US
Practice Address - Phone:562-424-8503
Practice Address - Fax:562-424-8772
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC36992106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA892652OtherVALUE OPTIONS
CA093481OtherHEALTHNET
CA235980191OtherUNITED BEHAVIORAL HEALTH
CA550010002625OtherPACIFIC CARE BEHAVIORAL
CA7633602OtherAETNA
CA10957501OtherBLUE CROSS