Provider Demographics
NPI:1962837104
Name:KUYKENDALL, CHARLES A (CAC II)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:KUYKENDALL
Suffix:
Gender:M
Credentials:CAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 WOODRUFF RD
Mailing Address - Street 2:SUITE A3
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-5730
Mailing Address - Country:US
Mailing Address - Phone:864-608-4578
Mailing Address - Fax:
Practice Address - Street 1:1200 WOODRUFF RD
Practice Address - Street 2:SUITE A3
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5730
Practice Address - Country:US
Practice Address - Phone:864-608-4578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1210026101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)