MEDICARE: MS. KISHA ANN PENDLETON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	3972	LA
2	101YM0800X	Mental Health Counselor	3972	LA
3	101YP2500X	Professional Counselor	3972	LA
4	103K00000X	Behavior Analyst	3972	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3972	OTHER	LA	LCSW

General Provider Information

NPI Number	:	1073955183
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KISHA ANN PENDLETON LCSW

Provider Business Mailing Address
First Line	:	2432 LARK ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70122-4322
Country	:	US
Telephone Number	:	504-908-5859
Fax Number	:

Provider Business Practice Location Address
First Line	:	2432 LARK ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70122-4322
Country	:	US
Telephone Number	:	504-908-5859
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2013
Last Update Date	:	07/18/2013

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