Healthcare Provider Details

I. General information

NPI: 1699120410
Provider Name (Legal Business Name): DR KENNEITH DURDEN OUTREACH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2016
Last Update Date: 04/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 MOONLIGHT TRL
PORT WENTWORTH GA
31407-3321
US

IV. Provider business mailing address

41 MOONLIGHT TRL
PORT WENTWORTH GA
31407-3321
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 Number
License Number State

VIII. Authorized Official

Name: KENNEITH DURDEN
Title or Position: CEO
Credential:
Phone: 404-909-2442