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General NPI Number Information
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NPI Number | 1760125843
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Entity Type | Individual
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Provider Name | CHARLES LUKE ENOMOTO SR.
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Gender | Male
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Dates
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Enumeration Date | 04/18/2022
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Last Update Date | 04/18/2022
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Provider Practice Location Address
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Address Line | 20 LAKE BLVD
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City | REDDING
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State | CA
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Zip | 96003-2512
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Country | US
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Telephone | 530-229-1416
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Fax |
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Provider Business Mailing Address
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Address Line | 12591 SHALON DR
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City | REDDING
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State | CA
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Zip | 96003-0382
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Country | US
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Telephone | 530-510-3149
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP1600X
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Taxonomy Name | Pastoral Counselor
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License Number |
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | A057340620
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License Number State | CA
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