Provider Demographics
NPI:1770044968
Name:KENDYL WATTS LLC
Entity Type:Organization
Organization Name:KENDYL WATTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENDYL
Authorized Official - Middle Name:
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-333-7649
Mailing Address - Street 1:2512 SE 25TH AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-2075
Mailing Address - Country:US
Mailing Address - Phone:503-333-7649
Mailing Address - Fax:
Practice Address - Street 1:2512 SE 25TH AVE STE 202
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-2075
Practice Address - Country:US
Practice Address - Phone:503-333-7649
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-29
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)