=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710774252
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVING WELL PSYCHOLOGICAL SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2025
-----------------------------------------------------
Last Update Date | 04/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 824 ELMWOOD PARK BLVD STE 156
-----------------------------------------------------
City | NEW ORLEANS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70123-3360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-414-1900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 824 ELMWOOD PARK BLVD STE 156
-----------------------------------------------------
City | NEW ORLEANS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70123-3360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-414-1900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER/PSYCHOLOGIST
-----------------------------------------------------
Name | DR. KENTRELL MONIQUE AVERY
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 225-439-8040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------