Provider Demographics
NPI:1811301575
Name:CONLAN, KENNETH JOHN
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOHN
Last Name:CONLAN
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 1:630 WINCHESTER DR.
Mailing Address - Street 2:
Mailing Address - City:NORCO
Mailing Address - State:CA
Mailing Address - Zip Code:92860
Mailing Address - Country:US
Mailing Address - Phone:951-515-1676
Mailing Address - Fax:
Practice Address - Street 1:630 WINCHESTER DR.
Practice Address - Street 2:
Practice Address - City:NORCO
Practice Address - State:CA
Practice Address - Zip Code:92860
Practice Address - Country:US
Practice Address - Phone:951-515-1676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health