=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700477338
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. KAN PSYCHOLOGICAL SERVICES INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2021
-----------------------------------------------------
Last Update Date | 09/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4695 CHABOT DR STE 200
-----------------------------------------------------
City | PLEASANTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94588-2756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-238-8932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4760 MAHOGANY ST
-----------------------------------------------------
City | DUBLIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94568-7672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-378-2284
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER AND LICENSED PSYCHOLOGIST
-----------------------------------------------------
Name | DR. WEN-TING MICHELLE KAN
-----------------------------------------------------
Credential | PHD, LMHC, MSED
-----------------------------------------------------
Telephone | 925-238-8932
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------