Provider Demographics
NPI:1598241234
Name:MAIN, KENDELL
Entity type:Individual
Prefix:
First Name:KENDELL
Middle Name:
Last Name:MAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 NE CONNERS AVE UNIT B-2
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6303
Mailing Address - Country:US
Mailing Address - Phone:541-323-5330
Mailing Address - Fax:
Practice Address - Street 1:1103 NE ELM ST
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-1664
Practice Address - Country:US
Practice Address - Phone:541-323-5338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health