Provider Demographics
NPI:1316432552
Name:SURATT, KEVIN D SR (LAADC-CA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:D
Last Name:SURATT
Suffix:SR
Gender:M
Credentials:LAADC-CA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1081 CAMINO DEL RIO S STE 129
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3544
Mailing Address - Country:US
Mailing Address - Phone:619-297-5131
Mailing Address - Fax:619-296-3846
Practice Address - Street 1:726 F ST FL 2
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-6303
Practice Address - Country:US
Practice Address - Phone:619-239-9691
Practice Address - Fax:619-239-9691
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-29
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCI04490315101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)