Provider Demographics
NPI:1861234262
Name:KENASTON, CYNTHIA
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:KENASTON
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 1:1400 N JOHNSON AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-1651
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 N JOHNSON AVE STE 101
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-1651
Practice Address - Country:US
Practice Address - Phone:760-593-9252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-07
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 225800000X, 146D00000X, 146L00000X, 146M00000X, 146N00000X, 226000000X, 374K00000X, 101YA0400X
CA17381405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation TherapistGroup - Multi-Specialty
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response AttendantGroup - Multi-Specialty
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, ParamedicGroup - Multi-Specialty
No146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, IntermediateGroup - Multi-Specialty
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Multi-Specialty
No226000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreational Therapist AssistantGroup - Multi-Specialty
No374K00000XNursing Service Related ProvidersReligious Nonmedical PractitionerGroup - Multi-Specialty
No405300000XOther Service ProvidersPrevention ProfessionalGroup - Multi-Specialty