Provider Demographics
NPI:1255866349
Name:POULLARD, ZURI
Entity Type:Individual
Prefix:
First Name:ZURI
Middle Name:
Last Name:POULLARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1639 RYAN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5948
Mailing Address - Country:US
Mailing Address - Phone:337-602-6391
Mailing Address - Fax:337-602-6392
Practice Address - Street 1:1639 RYAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5948
Practice Address - Country:US
Practice Address - Phone:337-602-6391
Practice Address - Fax:337-602-6392
Is Sole Proprietor?:No
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2203783030OtherKINGDOM EXPRESSIONS LLC BEHAVIORAL HEALTH- MHS