Provider Demographics
NPI:1023536851
Name:EZIDORE, KENMEISHA NORLONDRA
Entity Type:Individual
Prefix:
First Name:KENMEISHA
Middle Name:NORLONDRA
Last Name:EZIDORE
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 1:522 FARRAR AVE
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70062-7211
Mailing Address - Country:US
Mailing Address - Phone:504-579-3746
Mailing Address - Fax:
Practice Address - Street 1:522 FARRAR AVE
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70062-7211
Practice Address - Country:US
Practice Address - Phone:504-579-3746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-31
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health