=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134015068
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAYSHON RENEE MCKENNERY LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2025
-----------------------------------------------------
Last Update Date | 06/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 605 AUSTIN AVE
-----------------------------------------------------
City | WACO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76701-2048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-592-9426
-----------------------------------------------------
Fax | 817-768-9727
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 605 AUSTIN AVE
-----------------------------------------------------
City | WACO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76701-2048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-592-9426
-----------------------------------------------------
Fax | 817-768-9727
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 72878
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------