Healthcare Provider Details

I. General information

NPI: 1093352700
Provider Name (Legal Business Name): KENNETH RAY SIMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2019
Last Update Date: 12/19/2019
Certification Date: 12/19/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 EXECUTIVE PARK BLVD STE 4900
SAN FRANCISCO CA
94134-3335
US

IV. Provider business mailing address

PO BOX 14594
SAN FRANCISCO CA
94114-0594
US

V. Phone/Fax

Practice location:
  • Phone: 510-326-4680
  • Fax: 415-656-0117
Mailing address:
  • Phone: 510-326-4680
  • Fax: 415-656-0117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number19767
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: