Healthcare Provider Details

I. General information

NPI: 1811315179
Provider Name (Legal Business Name): KENNETH RICHARD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2014
Last Update Date: 04/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 W HUTCHINSON AVE
CROWLEY LA
70526-4124
US

IV. Provider business mailing address

1607 W GROLEE ST
OPELOUSAS LA
70570-2721
US

V. Phone/Fax

Practice location:
  • Phone: 337-788-7984
  • Fax: 337-788-7986
Mailing address:
  • Phone: 337-788-7984
  • Fax: 337-788-7986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: