Healthcare Provider Details

I. General information

NPI: 1346373248
Provider Name (Legal Business Name): KENNETH A MOKAN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BROADWAY STE 210
EL CAJON CA
92021-4899
US

IV. Provider business mailing address

8995 SILVER CT
SANTEE CA
92071-3248
US

V. Phone/Fax

Practice location:
  • Phone: 619-401-5500
  • Fax: 619-401-5454
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number22771
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: