Healthcare Provider Details

I. General information

NPI: 1184895930
Provider Name (Legal Business Name): KENNEITH DURDEN LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2008
Last Update Date: 07/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7306 GA HIGHWAY 21 STE 101-225
PORT WENTWORTH GA
31407-9274
US

IV. Provider business mailing address

7306 GA HIGHWAY 21 STE 101-225
PORT WENTWORTH GA
31407-9274
US

V. Phone/Fax

Practice location:
  • Phone: 404-909-2442
  • Fax:
Mailing address:
  • Phone: 404-909-2442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC005202
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: