Provider Demographics
NPI:1760125843
Name:ENOMOTO, CHARLES LUKE SR
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LUKE
Last Name:ENOMOTO
Suffix:SR
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 1:12591 SHALON DR
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96003-0382
Mailing Address - Country:US
Mailing Address - Phone:530-510-3149
Mailing Address - Fax:
Practice Address - Street 1:20 LAKE BLVD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96003-2512
Practice Address - Country:US
Practice Address - Phone:530-229-1416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YP1600X
CAA057340620101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1912215492OtherTRI-WEST