Provider Demographics
NPI:1275012635
Name:CHARLES, KEENA DEANE (LAC-TS)
Entity type:Individual
Prefix:MRS
First Name:KEENA
Middle Name:DEANE
Last Name:CHARLES
Suffix:
Gender:
Credentials:LAC-TS
Other - Prefix:
Other - First Name:KEENA
Other - Middle Name:D
Other - Last Name:PACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2620 E 21ST ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-2248
Mailing Address - Country:US
Mailing Address - Phone:316-214-1967
Mailing Address - Fax:316-660-6662
Practice Address - Street 1:939 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-3608
Practice Address - Country:US
Practice Address - Phone:316-263-8807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-07
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
KS101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS83-1206206OtherTAX IDENTIFICATION