Healthcare Provider Details

I. General information

NPI: 1902721855
Provider Name (Legal Business Name): KENDALL J CHARLES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 SW 11TH ST
CHEHALIS WA
98532-4728
US

IV. Provider business mailing address

375 SW 11TH ST
CHEHALIS WA
98532-4728
US

V. Phone/Fax

Practice location:
  • Phone: 360-740-3449
  • Fax:
Mailing address:
  • Phone: 360-740-3449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAAR.CG.70003994
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: