Healthcare Provider Details

I. General information

NPI: 1083069355
Provider Name (Legal Business Name): KENYATTA AVERY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4255 E BROOKSTOWN DR
BATON ROUGE LA
70805-4603
US

IV. Provider business mailing address

4255 E BROOKSTOWN DR
BATON ROUGE LA
70805-4603
US

V. Phone/Fax

Practice location:
  • Phone: 225-291-9646
  • Fax: 225-250-5677
Mailing address:
  • Phone: 225-250-5677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number9391
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: