Healthcare Provider Details

I. General information

NPI: 1154698892
Provider Name (Legal Business Name): KINGDOM SOURCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2011
Last Update Date: 11/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2506 JOHNSTON ST
LAFAYETTE LA
70503-3238
US

IV. Provider business mailing address

3226 GRAND POINT HWY
BREAUX BRIDGE LA
70517-6221
US

V. Phone/Fax

Practice location:
  • Phone: 337-456-6166
  • Fax: 337-456-4830
Mailing address:
  • Phone: 337-456-6166
  • Fax: 337-456-4830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: WINFORD LOUIS AMOS
Title or Position: DIRECTOR/ OWNER
Credential: LPC, LAC, CCS
Phone: 337-456-6166