Provider Demographics
NPI:1174972947
Name:KERN, PAUL TRAVIS (CDAC)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:TRAVIS
Last Name:KERN
Suffix:
Gender:M
Credentials:CDAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1847
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:380-423-0203
Mailing Address - Fax:360-577-0269
Practice Address - Street 1:305 PACIFIC AVE S STE 102
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-1638
Practice Address - Country:US
Practice Address - Phone:360-577-7442
Practice Address - Fax:360-577-7904
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-12
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106S00000X
WACP 60041391101YA0400X, 101YA0400X
OR16R21171M00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator