Healthcare Provider Details

I. General information

NPI: 1710355714
Provider Name (Legal Business Name): KASEY GENTRY WITHERINGTON M.ED.,COUNSELING
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2015
Last Update Date: 09/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4133 ADELINE LN
MONROE LA
71201-2175
US

IV. Provider business mailing address

1818 AVENUE OF AMERICA
MONROE LA
71201-4530
US

V. Phone/Fax

Practice location:
  • Phone: 318-381-4221
  • Fax:
Mailing address:
  • Phone: 318-998-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number3816
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: