Healthcare Provider Details

I. General information

NPI: 1396181947
Provider Name (Legal Business Name): PENNY KINGSTON CADC II
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2013
Last Update Date: 05/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 E 17TH ST SUITE B
SANTA ANA CA
92705-8521
US

IV. Provider business mailing address

1525 E 17TH ST SUITE B
SANTA ANA CA
92705-8521
US

V. Phone/Fax

Practice location:
  • Phone: 714-542-0400
  • Fax:
Mailing address:
  • Phone: 714-542-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: