Healthcare Provider Details

I. General information

NPI: 1861311466
Provider Name (Legal Business Name): KEITH GERARD FAYARD JR. CTI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

564 BRAXTON RD
DODSON LA
71422-3880
US

IV. Provider business mailing address

564 BRAXTON RD
DODSON LA
71422-3880
US

V. Phone/Fax

Practice location:
  • Phone: 318-648-2426
  • Fax:
Mailing address:
  • Phone: 318-648-2426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCIT-6174
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: