Healthcare Provider Details

I. General information

NPI: 1346785367
Provider Name (Legal Business Name): KINGDOM EXPRESSIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2016
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1639 RYAN ST STE B
LAKE CHARLES LA
70601-5948
US

IV. Provider business mailing address

1634 RYAN ST
LAKE CHARLES LA
70601-5949
US

V. Phone/Fax

Practice location:
  • Phone: 888-859-4202
  • Fax:
Mailing address:
  • Phone: 376-026-3913
  • Fax: 337-602-6392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: SHAKERA L MCKENZIE
Title or Position: CEO
Credential:
Phone: 337-602-6391