Healthcare Provider Details

I. General information

NPI: 1205319035
Provider Name (Legal Business Name): KEVIN B NIEHAUS MSE, PSYD, LPCC,
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2018
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2617 RIPLEY AVE
REDONDO BEACH CA
90278-4553
US

IV. Provider business mailing address

2617 RIPLEY AVE
REDONDO BEACH CA
90278-4553
US

V. Phone/Fax

Practice location:
  • Phone: 657-233-0374
  • Fax:
Mailing address:
  • Phone: 657-233-0374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPCC8824
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: