Basic Information
| Provider Information | |||||||||
| NPI: | 1235661323 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERRELL | ||||||||
| FirstName: | KEWON | ||||||||
| MiddleName: | HIKEEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 N THOMAS DR | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711076503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184248345 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 N THOMAS DR | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711076503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184248345 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2017 | ||||||||
| LastUpdateDate: | 03/29/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 522089886 | 05 | LA | MEDICAID |