=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053460733
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH J DEAVER LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15951 LOS GATOS BLVD STE 18
-----------------------------------------------------
City | LOS GATOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95032-3488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-358-9596
-----------------------------------------------------
Fax | 408-358-9596
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15951 LOS GATOS BLVD STE 18
-----------------------------------------------------
City | LOS GATOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95032-3488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-358-9596
-----------------------------------------------------
Fax | 408-358-9596
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCS16585
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------