Provider Demographics
NPI:1992711980
Name:BAUM, KENNETH ALAN
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ALAN
Last Name:BAUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2141 MONTROSE DR
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91362-2436
Mailing Address - Country:US
Mailing Address - Phone:805-497-1852
Mailing Address - Fax:805-497-1852
Practice Address - Street 1:5655 LINDERO CANYON RD STE 621
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91362-4052
Practice Address - Country:US
Practice Address - Phone:805-497-1852
Practice Address - Fax:805-497-1852
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8736103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPF0087360Medicaid
CACP8736Medicare ID - Type Unspecified