Basic Information
| Provider Information | |||||||||
| NPI: | 1932684479 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENNERSON | ||||||||
| FirstName: | KAYLA | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1003 HUGH WALLIS RD S STE B2 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705082528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372054444 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1003 HUGH WALLIS RD S STE B2 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705082528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372054444 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2018 | ||||||||
| LastUpdateDate: | 04/16/2019 | ||||||||
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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 | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 103K00000X | 010590457 | LA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 47-3121002 | 01 | LA | MENTAL HEALTH | OTHER |