Active NPI
Kenneth Park
- Clinical Social Worker
- San Bernardino, CA
National Provider Identifier
1255768974
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Social Worker
- License
- 68555
- Practice address
- 2372 Sterling Ave
San Bernardino, CA 92404-4624 - Phone
- (310) 421-9405
- NPI assigned
- Sep 27, 2013
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | 68555 | CA | Primary |
Addresses
Primary practice location
2372 Sterling Ave
San Bernardino, CA 92404-4624
Mailing address
2372 Sterling Ave
San Bernardino, CA 92404-4624
Phone (310) 421-9405
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| ASW #68555 | Other | CA | BOARD OF BEHAVIORAL SCIENCES |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 68555 | CA | MD | Clinical Social Worker |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1380240000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1487289600000",
"number": "1255768974",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2372 STERLING AVE",
"city": "SAN BERNARDINO",
"state": "CA",
"postal_code": "924044624",
"telephone_number": "310-421-9405"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2372 STERLING AVE",
"city": "SAN BERNARDINO",
"state": "CA",
"postal_code": "924044624",
"telephone_number": "310-421-9405"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PARK",
"first_name": "KENNETH",
"name_prefix": "Mr.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2013-09-27",
"last_updated": "2017-02-17",
"status": "A"
},
"taxonomies": [
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "CA",
"license": "68555",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BOARD OF BEHAVIORAL SCIENCES",
"identifier": "ASW #68555",
"state": "CA"
}
],
"endpoints": [],
"other_names": []
}Other providers in San Bernardino, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 17, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.