Basic Information
Provider Information | |||||||||
NPI: | 1730282138 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KENNEMER | ||||||||
FirstName: | KORDELL | ||||||||
MiddleName: | NOLTAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSYD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 14900 | ||||||||
Address2: | DHS OFS IRS DBA OREGON STATE HOSPITAL | ||||||||
City: | SALEM | ||||||||
State: | OR | ||||||||
PostalCode: | 973095016 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5039459840 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 619 MADISON ST STE 108 | ||||||||
Address2: |   | ||||||||
City: | OREGON CITY | ||||||||
State: | OR | ||||||||
PostalCode: | 97045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5033873957 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/07/2006 | ||||||||
LastUpdateDate: | 11/16/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/16/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 1633 | OR | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.