Healthcare Provider Details

I. General information

NPI: 1518272129
Provider Name (Legal Business Name): KEITH B. KESSEL M.D., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2010
Last Update Date: 08/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 OLIVE ST STE 109
SHREVEPORT LA
71104-2250
US

IV. Provider business mailing address

745 OLIVE ST STE 109
SHREVEPORT LA
71104-2250
US

V. Phone/Fax

Practice location:
  • Phone: 318-221-6070
  • Fax: 318-221-6069
Mailing address:
  • Phone: 318-221-6070
  • Fax: 318-221-6069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number10227R
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number10227R
License Number StateLA

VIII. Authorized Official

Name: CANDEE CARMAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 318-221-6070