Healthcare Provider Details

I. General information

NPI: 1811360191
Provider Name (Legal Business Name): KENNA DIXON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

401 RAINBOW DR UNIT 36
PINEVILLE LA
71360-6979
US

IV. Provider business mailing address

1800 COMMUNITY
CLINTON MO
64735-8804
US

V. Phone/Fax

Practice location:
  • Phone: 318-484-6592
  • Fax:
Mailing address:
  • Phone: 660-890-8186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1382
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: