1588963573 NPI number — MR. KENT A WEISHAUS LCSW

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588963573 NPI number — MR. KENT A WEISHAUS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEISHAUS
Provider First Name:
KENT
Provider Middle Name:
A
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588963573
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 723
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95402-0723
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-288-5228
Provider Business Mailing Address Fax Number:
951-257-0042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
54240 RIDGEVIEW DR
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
IDYLLWILD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-288-5228
Provider Business Practice Location Address Fax Number:
951-257-0042
Provider Enumeration Date:
03/16/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LCS 28772 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: LCSW28772 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NONE . This is a "NONE" identifier . This identifiers is of the category "OTHER".




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