MEDICARE: KENNETH SUBOTNIK, PH.D., INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center	PSY12770	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	PSY12770	OTHER	CA	CALIFORNIA PSYCHOLOGIST LICENSE

General Provider Information

NPI Number	:	1598924953
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENNETH SUBOTNIK, PH.D., INC

Provider Business Mailing Address
First Line	:	10850 WILSHIRE BLVD STE 240
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-4308
Country	:	US
Telephone Number	:	310-824-4600
Fax Number	:

Provider Business Practice Location Address
First Line	:	10850 WILSHIRE BLVD STE 240
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-4308
Country	:	US
Telephone Number	:	310-824-4600
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. KENNETH LEE SUBOTNIK
Credential	:	PH.D.
Telephone Number	:	310-824-4600

Provider Enumeration Date	:	06/02/2008
Last Update Date	:	06/02/2008

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