Healthcare Provider Details

I. General information

NPI: 1649616087
Provider Name (Legal Business Name): KENNETH DAVID SEKULIC PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2013
Last Update Date: 05/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3075 CORBINA ALY SUITE 1
SAN DIEGO CA
92136-5112
US

IV. Provider business mailing address

9388 BABAUTA RD SUITE 128
SAN DIEGO CA
92129-4932
US

V. Phone/Fax

Practice location:
  • Phone: 619-556-7641
  • Fax: 619-556-8413
Mailing address:
  • Phone: 619-556-7641
  • Fax: 619-556-8413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number016339
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: