Provider Demographics
NPI:1275034761
Name:PAUL, KANISHA
Entity Type:Individual
Prefix:
First Name:KANISHA
Middle Name:
Last Name:PAUL
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 1:426 SOUTH KINLER STREET
Mailing Address - Street 2:
Mailing Address - City:BOUTTE
Mailing Address - State:LA
Mailing Address - Zip Code:70039
Mailing Address - Country:US
Mailing Address - Phone:504-223-4353
Mailing Address - Fax:504-558-4937
Practice Address - Street 1:426 SOUTH KINLER STREET
Practice Address - Street 2:
Practice Address - City:BOUTTE
Practice Address - State:LA
Practice Address - Zip Code:70039
Practice Address - Country:US
Practice Address - Phone:504-223-4353
Practice Address - Fax:504-558-4937
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health