Healthcare Provider Details

I. General information

NPI: 1417466400
Provider Name (Legal Business Name): KENNETH MICHEAL TOWNSEND PHD, MBA, BS, AA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2017
Last Update Date: 05/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19295 N 3RD ST STE 2
COVINGTON LA
70433-8897
US

IV. Provider business mailing address

19295 N 3RD ST STE 2
COVINGTON LA
70433-8897
US

V. Phone/Fax

Practice location:
  • Phone: 985-400-5901
  • Fax: 985-400-5164
Mailing address:
  • Phone: 985-400-5901
  • Fax: 985-400-5164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number800877319
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: