Healthcare Provider Details

I. General information

NPI: 1053789735
Provider Name (Legal Business Name): KASEY WITHERINGTON COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2015
Last Update Date: 09/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 AVENUE OF AMERICA
MONROE LA
71201-4530
US

IV. Provider business mailing address

4133 ADELINE LN
MONROE LA
71201-2175
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3816
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number3816
License Number StateLA

VIII. Authorized Official

Name: MRS. KASEY GENTRY WITHERINGTON
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: M.ED., COUNSELING
Phone: 318-381-4221