Healthcare Provider Details

I. General information

NPI: 1093591356
Provider Name (Legal Business Name): KISHA KUYKENDALL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2023
Last Update Date: 09/04/2023
Certification Date: 09/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HARTSFIELD CENTER PKWY STE 500
ATLANTA GA
30354-1377
US

IV. Provider business mailing address

100 HARTSFIELD CENTER PKWY STE 500
ATLANTA GA
30354-1377
US

V. Phone/Fax

Practice location:
  • Phone: 404-709-5347
  • Fax:
Mailing address:
  • Phone: 404-709-5347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC013666
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: