Provider Demographics
NPI:1760922033
Name:KYNISTON, DARREL KYNISTON (CADC 1)
Entity Type:Individual
Prefix:MR
First Name:DARREL
Middle Name:KYNISTON
Last Name:KYNISTON
Suffix:
Gender:M
Credentials:CADC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1497 S E ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97630
Mailing Address - Country:US
Mailing Address - Phone:541-947-6021
Mailing Address - Fax:
Practice Address - Street 1:215 NORTH G STREET
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:OR
Practice Address - Zip Code:97630
Practice Address - Country:US
Practice Address - Phone:541-947-6021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORX-9-1-2018101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR16-07-13 X-9-1-2018OtherCADC1 LICENSE ACCBO