MEDICARE: DR KENNEITH DURDEN OUTREACH

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	101YP2500X	Professional Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699120410
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR KENNEITH DURDEN OUTREACH

Provider Business Mailing Address
First Line	:	41 MOONLIGHT TRL
Second Line	:
City	:	PORT WENTWORTH
State	:	GA
Zip	:	31407-3321
Country	:	US
Telephone Number	:	404-909-2442
Fax Number	:

Provider Business Practice Location Address
First Line	:	41 MOONLIGHT TRL
Second Line	:
City	:	PORT WENTWORTH
State	:	GA
Zip	:	31407-3321
Country	:	US
Telephone Number	:	404-909-2442
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	KENNEITH DURDEN
Credential	:
Telephone Number	:	404-909-2442

Provider Enumeration Date	:	04/29/2016
Last Update Date	:	04/29/2016

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