MEDICARE: KENNETH HILLIARD

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

General Provider Information

NPI Number	:	1730838947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH HILLIARD

Provider Business Mailing Address
First Line	:	921 E DUPONT RD # 909
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1551
Country	:	US
Telephone Number	:	260-797-5892
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 E RUDISILL BLVD STE B102
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46806-1756
Country	:	US
Telephone Number	:	126-079-7589
Fax Number	:

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

Provider Enumeration Date	:	03/23/2022
Last Update Date	:	03/23/2022

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