Healthcare Provider Details

I. General information

NPI: 1306783675
Provider Name (Legal Business Name): DR. KENNETH MARVIN NOWACK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2621 6TH ST APT 2
SANTA MONICA CA
90405-4432
US

IV. Provider business mailing address

2208 6TH ST
SANTA MONICA CA
90405-2406
US

V. Phone/Fax

Practice location:
  • Phone: 310-721-2918
  • Fax:
Mailing address:
  • Phone: 310-721-2918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY13758
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: