Healthcare Provider Details

I. General information

NPI: 1720451073
Provider Name (Legal Business Name): MRS. KENETTA HERRIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2015
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3510 LINWOOD AVE
SHREVEPORT LA
71103
US

IV. Provider business mailing address

6009 FINANCIAL PLZ STE 105
SHREVEPORT LA
71129-2615
US

V. Phone/Fax

Practice location:
  • Phone: 318-636-4194
  • Fax:
Mailing address:
  • Phone: 318-670-8858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: