Basic Information
| Provider Information | |||||||||
| NPI: | 1790207231 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KWON | ||||||||
| FirstName: | SANGIL | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7231 BOULDER AVE | ||||||||
| Address2: | STE 295 | ||||||||
| City: | HIGHLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923463313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092835327 | ||||||||
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| Practice Location | |||||||||
| Address1: | 24511 W JAYNE AVE | ||||||||
| Address2: | |||||||||
| City: | COALINGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932109503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5599354300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2017 | ||||||||
| LastUpdateDate: | 01/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 29142 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 021523 | NY | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.