Provider Demographics
NPI:1699279679
Name:KARYADI, KENNY A (PHD)
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:A
Last Name:KARYADI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 W HOSPITALITY LN
Mailing Address - Street 2:STE 300
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3241
Mailing Address - Country:US
Mailing Address - Phone:909-651-4518
Mailing Address - Fax:909-651-4586
Practice Address - Street 1:11835 W OLYMPIC BLVD STE 1265E
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-5814
Practice Address - Country:US
Practice Address - Phone:310-273-4843
Practice Address - Fax:310-273-5056
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29812103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist