Provider Demographics
NPI:1629205570
Name:CHANDLER, KENNETH E
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:E
Last Name:CHANDLER
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:KENNETH
Other - Middle Name:E
Other - Last Name:CHANDLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CADC
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-367-3069
Mailing Address - Fax:208-367-3002
Practice Address - Street 1:6138 W EMERALD ST STE B
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8857
Practice Address - Country:US
Practice Address - Phone:208-367-3069
Practice Address - Fax:208-367-3002
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1280008101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)