Healthcare Provider Details

I. General information

NPI: 1487015269
Provider Name (Legal Business Name): KEVIN MICHAEL LEE GEBKEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2016
Last Update Date: 03/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 N MAIN ST #73
WALNUT CREEK CA
94596-4609
US

IV. Provider business mailing address

1630 N MAIN ST #73
WALNUT CREEK CA
94596-4609
US

V. Phone/Fax

Practice location:
  • Phone: 925-935-3351
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number33230
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: