MEDICARE: DR. HEIDI Y KWAN PH.D.

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	103TC2200X	Clinical Child & Adolescent Psychologist	PSY15019	CA

General Provider Information

NPI Number	:	1649382680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HEIDI Y KWAN PH.D.

Provider Business Mailing Address
First Line	:	3585 MAPLE ST
Second Line	:	STE 255
City	:	VENTURA
State	:	CA
Zip	:	93003-9147
Country	:	US
Telephone Number	:	805-650-0657
Fax Number	:	805-654-1098

Provider Business Practice Location Address
First Line	:	3585 MAPLE ST
Second Line	:	STE 255
City	:	VENTURA
State	:	CA
Zip	:	93003-9147
Country	:	US
Telephone Number	:	805-650-0657
Fax Number	:	805-654-1098

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	06/23/2020

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