1962552844 NPI number — KENDALL TODD CARMAN-WAGNER LICSW

Table of content: KENDALL TODD CARMAN-WAGNER LICSW (NPI 1962552844)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962552844 NPI number — KENDALL TODD CARMAN-WAGNER LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARMAN-WAGNER
Provider First Name:
KENDALL
Provider Middle Name:
TODD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962552844
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 EQUESTRIAN WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALLA WALLA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99362-6220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-529-1496
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1012 S 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99328-1606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-382-2531
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LW00005301 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YA0400X , with the licence number: CP00000091 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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