Provider Demographics
NPI:1144346818
Name:KASNER, EDMUND SHANE (LCSW, MSW, MAM)
Entity type:Individual
Prefix:
First Name:EDMUND
Middle Name:SHANE
Last Name:KASNER
Suffix:
Gender:M
Credentials:LCSW, MSW, MAM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5015 CANYON CREST DRIVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507
Mailing Address - Country:US
Mailing Address - Phone:951-276-0696
Mailing Address - Fax:951-276-0885
Practice Address - Street 1:5015 CANYON CREST DR
Practice Address - Street 2:SUITE 105
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-6000
Practice Address - Country:US
Practice Address - Phone:951-276-0696
Practice Address - Fax:951-276-0885
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS67371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA188407Medicaid
CA33BFO9Medicaid
CA33BFA9Medicaid
CALCS067370OtherBLUE SHIELD PIN