Healthcare Provider Details

I. General information

NPI: 1073955183
Provider Name (Legal Business Name): KISHA ANN PENDLETON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2013
Last Update Date: 07/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2432 LARK ST
NEW ORLEANS LA
70122-4322
US

IV. Provider business mailing address

2432 LARK ST
NEW ORLEANS LA
70122-4322
US

V. Phone/Fax

Practice location:
  • Phone: 504-908-5859
  • Fax:
Mailing address:
  • Phone: 504-908-5859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3972
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3972
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3972
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number3972
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: