Provider Demographics
NPI:1730282138
Name:KENNEMER, KORDELL NOLTAN (PSYD)
Entity Type:Individual
Prefix:
First Name:KORDELL
Middle Name:NOLTAN
Last Name:KENNEMER
Suffix:
Gender:M
Credentials:PSYD
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 14900
Mailing Address - Street 2:DHS OFS IRS DBA OREGON STATE HOSPITAL
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97309-5016
Mailing Address - Country:US
Mailing Address - Phone:503-945-9840
Mailing Address - Fax:
Practice Address - Street 1:619 MADISON ST STE 108
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045
Practice Address - Country:US
Practice Address - Phone:503-387-3957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1633103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical