Provider Demographics
NPI:1003338534
Name:DENNIS, KEYORKA K
Entity Type:Individual
Prefix:MS
First Name:KEYORKA
Middle Name:K
Last Name:DENNIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 NEW HIGHWAY 51 STE C
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-6512
Mailing Address - Country:US
Mailing Address - Phone:985-651-0020
Mailing Address - Fax:985-651-0027
Practice Address - Street 1:3205 NEW HIGHWAY 51 STE C
Practice Address - Street 2:
Practice Address - City:LA PLACE
Practice Address - State:LA
Practice Address - Zip Code:70068-6512
Practice Address - Country:US
Practice Address - Phone:504-702-3995
Practice Address - Fax:504-702-3994
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 171M00000X
LA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS$$$$$$$$$Medicaid