Provider Demographics
NPI:1477297265
Name:NEBEKER, KENDALL LOGAN
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:LOGAN
Last Name:NEBEKER
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:PO BOX 20310
Mailing Address - Street 2:PMB 55984
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-1970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4943 N 29TH E # B
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-1314
Practice Address - Country:US
Practice Address - Phone:307-257-5487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1396085718Medicaid