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General NPI Number Information
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NPI Number | 1386142545
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Entity Type | Organization
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Legal Business Name | KHONSU, LLC
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Dates
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Enumeration Date | 01/23/2018
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Last Update Date | 01/22/2021
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Provider Practice Location Address
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Address Line | 3419 NW EVANGELINE TRWY STE A-1
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City | CARENCRO
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State | LA
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Zip | 70520-6241
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Country | US
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Telephone | 337-319-1315
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Fax |
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Provider Business Mailing Address
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Address Line | 3419 NW EVANGELINE TRWY STE A-1
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City | CARENCRO
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State | LA
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Zip | 70520-6241
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Country | US
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Telephone | 337-319-1315
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | AMANDA LEE HOLMES
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Credential |
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Telephone | 337-345-5390
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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