Provider Demographics
NPI:1790201432
Name:CHADWICK, KENNETH CHARLES JR
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:CHARLES
Last Name:CHADWICK
Suffix:JR
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 1:9825 MAGNOLIA AVE STE B
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3565
Mailing Address - Country:US
Mailing Address - Phone:951-509-2499
Mailing Address - Fax:
Practice Address - Street 1:40925 COUNTY CENTER DR STE 200
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-6037
Practice Address - Country:US
Practice Address - Phone:951-600-6360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1466610422171M00000X, 101YA0400X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist