Provider Demographics
NPI:1104044148
Name:COLE, KENYON Q
Entity Type:Individual
Prefix:MR
First Name:KENYON
Middle Name:Q
Last Name:COLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8619 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90305-2330
Mailing Address - Country:US
Mailing Address - Phone:310-677-9019
Mailing Address - Fax:310-677-9401
Practice Address - Street 1:8619 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90305-2330
Practice Address - Country:US
Practice Address - Phone:310-677-9019
Practice Address - Fax:310-677-9401
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)