Provider Demographics
NPI:1528515236
Name:KGN PSYCHOLOGICAL SERVICES, INC.
Entity type:Organization
Organization Name:KGN PSYCHOLOGICAL SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GRANGER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:949-381-1519
Mailing Address - Street 1:222 W MAIN ST
Mailing Address - Street 2:#101
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-7720
Mailing Address - Country:US
Mailing Address - Phone:949-381-1519
Mailing Address - Fax:
Practice Address - Street 1:222 W MAIN ST
Practice Address - Street 2:#101
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-7720
Practice Address - Country:US
Practice Address - Phone:949-381-1519
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-10
Last Update Date:2016-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28523103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty