Provider Demographics
NPI:1114757218
Name:WARREN, KENNETH (CADC, CODP I)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:WARREN
Suffix:
Gender:M
Credentials:CADC, CODP I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 JOHN DEERE RD
Mailing Address - Street 2:
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-9607
Mailing Address - Country:US
Mailing Address - Phone:309-792-0292
Mailing Address - Fax:
Practice Address - Street 1:1607 JOHN DEERE RD
Practice Address - Street 2:
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-9607
Practice Address - Country:US
Practice Address - Phone:309-792-0292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-03
Last Update Date:2024-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36152101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)