Basic Information
| Provider Information | |||||||||
| NPI: | 1932789146 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREEMAN | ||||||||
| FirstName: | KENNETHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8326 KELWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708064803 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 751 BAYOU PINES EAST DR STE C | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706017196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374333292 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2021 | ||||||||
| LastUpdateDate: | 04/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | N | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.