=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699120410
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR KENNEITH DURDEN OUTREACH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2016
-----------------------------------------------------
Last Update Date | 04/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41 MOONLIGHT TRL
-----------------------------------------------------
City | PORT WENTWORTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31407-3321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-909-2442
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41 MOONLIGHT TRL
-----------------------------------------------------
City | PORT WENTWORTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31407-3321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-909-2442
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | KENNEITH DURDEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-909-2442
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------