Provider Demographics
NPI:1295192052
Name:KETCHENS, ELYDIA
Entity Type:Individual
Prefix:
First Name:ELYDIA
Middle Name:
Last Name:KETCHENS
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 1:3221 BEHRMAN PL
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70114-8200
Mailing Address - Country:US
Mailing Address - Phone:504-263-2800
Mailing Address - Fax:504-263-2900
Practice Address - Street 1:3221 BEHRMAN PL
Practice Address - Street 2:SUITE 201
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70114-8200
Practice Address - Country:US
Practice Address - Phone:504-263-2800
Practice Address - Fax:504-263-2900
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA104100000XMedicaid