Provider Demographics
NPI:1932233178
Name:EL CAMINO PSYCHOLOGY SERVICES. PC
Entity Type:Organization
Organization Name:EL CAMINO PSYCHOLOGY SERVICES. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:KILBOURNE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:760-722-4233
Mailing Address - Street 1:2181 S EL CAMINO REAL STE 307
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-6288
Mailing Address - Country:US
Mailing Address - Phone:760-722-4233
Mailing Address - Fax:760-722-4232
Practice Address - Street 1:2181 S EL CAMINO REAL STE 307
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-6288
Practice Address - Country:US
Practice Address - Phone:760-722-4233
Practice Address - Fax:760-722-4232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10467103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY10467Medicaid
CAPSY10467Medicaid