Provider Demographics
NPI:1962552844
Name:CARMAN-WAGNER, KENDALL TODD (LICSW)
Entity type:Individual
Prefix:
First Name:KENDALL
Middle Name:TODD
Last Name:CARMAN-WAGNER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 EQUESTRIAN WAY
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-6220
Mailing Address - Country:US
Mailing Address - Phone:509-529-1496
Mailing Address - Fax:
Practice Address - Street 1:1012 S 3RD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:WA
Practice Address - Zip Code:99328-1606
Practice Address - Country:US
Practice Address - Phone:509-382-2531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000053011041C0700X
WACP00000091101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8809083Medicare PIN