Provider Demographics
NPI:1720496235
Name:PHELPS, W. KANE
Entity Type:Individual
Prefix:
First Name:W. KANE
Middle Name:
Last Name:PHELPS
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 1:816 HAVERFORD AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-4300
Mailing Address - Country:US
Mailing Address - Phone:310-573-9771
Mailing Address - Fax:
Practice Address - Street 1:860 VIA DE LA PAZ
Practice Address - Street 2:SUITE F3
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-3608
Practice Address - Country:US
Practice Address - Phone:310-573-9771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-28
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25088106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist