Healthcare Provider Details

I. General information

NPI: 1881559300
Provider Name (Legal Business Name): KENNITH DRA KIRK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 E HOSPITALITY LANE
SAN BERNARDINO CA
92408
US

IV. Provider business mailing address

27050 STRATFORD ST
HIGHLAND CA
92346
US

V. Phone/Fax

Practice location:
  • Phone: 909-891-1599
  • Fax: 877-306-6790
Mailing address:
  • Phone: 714-329-3366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: