Provider Demographics
NPI:1528286580
Name:KIRKLAND, DAVID GLEN (CAS)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:GLEN
Last Name:KIRKLAND
Suffix:
Gender:M
Credentials:CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 DEL VALE AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4800
Mailing Address - Country:US
Mailing Address - Phone:209-571-0972
Mailing Address - Fax:209-578-1085
Practice Address - Street 1:1028 RENO AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95351-1127
Practice Address - Country:US
Practice Address - Phone:209-579-1103
Practice Address - Fax:209-578-1085
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA02045384101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)