Healthcare Provider Details

I. General information

NPI: 1730961939
Provider Name (Legal Business Name): MICHAEL DEAN KEWISH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 10/23/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25115 AVENUE STANFORD # A103
VALENCIA CA
91355-1290
US

IV. Provider business mailing address

26102 GALVEZ CT
SANTA CLARITA CA
91355-3349
US

V. Phone/Fax

Practice location:
  • Phone: 661-468-7405
  • Fax:
Mailing address:
  • Phone: 661-904-1613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: