Basic Information
| Provider Information | |||||||||
| NPI: | 1811479207 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENYAN | ||||||||
| FirstName: | GEORGIA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5180 LINTON CUTOFF RD | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710068770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186175953 | ||||||||
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| Practice Location | |||||||||
| Address1: | 856 TEXAS AVE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711013400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184296938 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2018 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1417252230 | 05 | LA | MEDICAID |